Differential diagnosis cervical conditions When systemic and viscerogenic sources of neck pain have been ruled out, the task facing the assessing clinician is to determine what cervical structure(s) are causing the client’s presenting symptoms. This is absolutely necessary for determining an effect Facet (or zygapophyseal) joint dysfunction is a possible source of neck pain. According to Hurley et al. (2022), the facet joints are considered the primary source of pain in 26%–70% of patients with chronic neck pain and 54%–60% of neck pain following whiplash injury. The C2–C3 and C5–C6 joints are most commonly implicated in neck pain, with C2–C3, C3–C4, and C4–C5 being the most radiologically involved (Hurley et al., 2022). treatment plan. Facet joint pain Healthcare consideration: Since research shows that the facet joints are frequently involved in both acute and chronic neck pain, physical therapists must be skilled at differentiating whether the facet joints are involved. Three ways to assess facet joint function are (1) looking at deficits in neck flexion, side bend, and rotation as each of the facet joints contributes their part to overall cervical motion; (2) observing the neck during flexion, rotation, and side bend to see if there is a visible restriction in motion at any particular level; and (3) providing posteroanterior pressure to each level of the cervical spine on both sides to determine if there is stiffness/decreased motion or pain at any level. AO and AA joints and neck pain The anatomy of atlantooccipital (AO) and atlantoaxial (AA) is uniquely different in the cervical spine. The AO joint is a synovial articulation between the convex occipital condyles of the skull and C1. The AA joint consists of the lateral articulations between C1 and C2 and the median articulation between the odontoid process and the posterior surface of the anterior arch of the atlas anteriorly and the transverse ligament posteriorly. The AO and AA joints provide mechanical stability between the head and cervical spine while allowing for significant movement. Approximately 33% of cervical spine flexion and extension comes from the AO joint. Over 50% of cervical spine rotation occurs at the AA joint. Pain related to AO or C0–C1 dysfunction tends to occur at the occipito-cervical region, in the retro-mastoid region, and in the upper cervical area. Pain related to dysfunction in C1–C2 most often occurs in the suboccipital area with radiation up to the back and head and down into the upper neck (Hurley et al., 2022). Self-Assessment Quiz Question #33 Another name for the articulation between the occipital condyles of the skull and C1 is: a. Atlanto-axial joint. b. Atlanto-occipital joint. c. Axial-occipital joint. d. C1-C2. Self-Assessment Quiz Question #34 The structure that runs posterior to the dens and provides stability to the C1/C2 articulation via the den is: a. Transverse ligament. b. Atlas ligament.
Case Study: Ben Barnes Mr. Barnes presents to physical therapy with complaints of neck pain. When asked to show you where the pain is, he puts his hand on the upper cervical spine and says, “Right here.” Based on this basic information, it seems that upper cervical dysfunction may explain his symptoms. Question What tests can you use to determine if upper cervical spine dysfunction is present? What symptom might accompany the presence of upper cervical spine dysfunction if it is present? Discussion Tests that can be used to determine if upper cervical dysfunction is present include (1) the head nod test, which isolates motion at the C0/C1 joints; (2) the flexion rotation test, which isolates motion at the C1/C2 joints; and (3) palpation of the upper cervical facet joints to determine if they are painful and/or demonstrate restricted motion, which can indicate involvement of these joints. C2 to C7 facet joints and neck pain Specific physical examination findings can be used to confirm a differential diagnosis of neck pain originating from the cervical spine. Hurley et al. (2022) identified the following exam findings as useful for diagnosing facet joint pain in the cervical spine: ● Cervical spine range of motion . Assessment of cervical flexion and extension, bilateral lateral flexion or side bend, and rotation can identify facet joint restrictions. Gross motion of the cervical spine is accomplished via the segmental contributions of each facet joint. Limitations in cervical range of motion 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 applied 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 segments. ● 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 laterally 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.
c. Atlantis ligament. a. Vertebral ligament.
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