Cervical osteopathy

The cervical region is a pathway between the head and the thorax consisting of vascular, musculoskeletal, and neural networks; it is one of the most common areas of dysfunction, often resulting in discomfort and impairment. It is imperative that any cervical dysfunction is treated with care. Therefore, understanding diagnostic steps and treatment of the cervical spine are of great importance in osteopathic medicine. Dysfunction may occur in a multitude of anatomical locations: paraspinal musculature, Occipital-atlantal (OA) joint, atlanto-axial (AA) joint, or any of the cervical vertebrae (C2–C7). Osteopathic treatment includes various myofascial techniques, muscle energy, facilitated positional release, Still technique, and high-velocity low-amplitude (HVLA).

Overview

• The cervical spine consists of seven vertebrae (C1–C7).
  • C3–C6 are typical vertebrae
  • C1, C2, and C7 are atypical vertebrae
• The vertebral arteries, veins, and sympathetic fibers pass through the transverse foramina before entering the foramen magnum.
• For more information, see the “Vertebral column” and “Head and neck region” articles.

Bones

• C1 (atlas)
  • Has no vertebral body, consists of an anterior and a posterior arch
  • Articulates with the occiput cranially and the axis caudally
• C2 (axis)
  • Characterized by the odontoid process (dens), which projects cranially from the vertebral body into the vertebral foramen of the atlas
  • Articulates with the atlas cranially.
• C2–C6: have bifid spinal processes

Muscles

• Sternocleidomastoid muscle
  • Originates from sternum and clavicle and inserts into the mastoid process
  • Function
    • Unilateral contraction: flexes the head laterally on the ipsilateral side and rotates the head to the contralateral side (i.e., STRA: sidebending toward, rotate away)
    • Bilateral contraction: flexes neck dorsally
    • Accessory respiratory muscles
• Scalene muscles (anterior, middle, and posterior scalene)
  • Originate from the transverse processes of cervical vertebrae (C2–C7) and insert into the first or second rib
    • Anterior and middle scalenes insert on the first rib
    • The posterior scalene inserts on the second rib.
  • Function
    • Unilateral contraction: ipsilateral flexion of the head
    • Bilateral contraction: flexion of the neck
    • Accessory respiratory muscle

A dysfunctional sternocleidomastoid muscle is characterized by being hypertonic and having the origin and insertion sites closer together.

Ligaments

• Transverse ligament
  • Attaches to the posterior aspect of the odontoid process to the lateral masses of C1
  • Holds the odontoid process in place
• Alar ligaments
  • Attach to the dens of C2 bilaterally and insert on the occipital condyles
  • Limit the axial rotation and sidebending in the occipital-atlanto-axial complex

Down syndrome and rheumatoid arthritis can weaken the alar and transverse ligaments leading to atlanto-axial subluxation. Applying HVLA to the cervical spine is contraindicated in these patients.

Innervation

• C1–C7 nerves exit superior to the pedicles of C1–C7.
• C8 nerves exit inferior to the pedicles of C7 because there is no C8 vertebra.
• Examples
  • Left C7 radiculitis: A left intervertebral disc herniation of C6–C7 will impinge the C7 cervical nerve root.
  • Left C7 radiculopathy: A left intervertebral disc herniation of C6–C7 will impinge the C7 cervical nerve root and cause muscle fatigue and hypoactive tricep reflex.
• For more information, see "Vertebral column" and “Spinal cord tracts and reflexes.”

Anatomical landmarks of the cervical spine

• C2: angle of mandible
• C3: level of hyoid
• C4: superior aspect of thyroid cartilage
• C5: body of thyroid cartilage
• C6: first cricoid ring
• C6 (anterior tubercle/transverse process): carotid tubercle
• T2: suprasternal notch

Overview

The OA joint is the “yes” joint (flexion/extension) and the AA joint is the “no” joint (rotation).

The AA joint does not have a sidebending component to its diagnosis.

Motion

• OA joint
  • Represents the motion of the occipital condyles on the atlas (C1)
  • Primary motion: flexion and extension
  • Secondary motion: sidebending
  • Sidebending and rotation occur in opposite directions (“opposite always”) with flexion or extension (e.g., an OA flexed, sidebent left and rotated right means the occiput on the atlas is flexed, sidebent left and rotated right (FS_LR_R).
• AA joint
  • Represents the atlas motion on axis (C2)
  • Primary motion: rotation (e.g., an AA rotated left means the atlas is rotated left on the axis)
• C2–C7 joints
  • Axes
    • Rotation: superior-inferior
    • Sidebending: anterior-posterior (∼ 45 degrees)
    • Flexion and extension: medial-lateral
  • Sidebending and rotation occur in the same direction

“Opposite always”: sidebending and rotation occur in opposite directions at the OA joint.

“Same side for the C-spine”: sidebending and rotation occur in the same direction at the cervical spine.

The greatest range of motion in the cervical spine is rotation.

Gross motion testing

Components

• Sidebending
• Flexion (forward bending)
• Extension (backward bending)
• Rotation

Approach

• Sidebending: assess using translation (osteopathy)
  • Position: supine, neutral
  • Translate the vertebrae in both directions equally (i.e., left and right)
    • Normal: The vertebra can be translated equally in both directions.
    • Dysfunction
      • If right translation is easier than to the left → vertebra sidebends easily to the left → sidebent left
      • If left translation is easier than to the right → vertebra sidebends easily to the right → sidebent right
    • Examples
      • A C3 restriction in right translation in the flexed position, suggests C3 is extended, rotated right, and sidebent right.
      • An OA joint restriction in right translation in the flexed position, suggests the occiput is extended, rotated left, and sidebent right (i.e., restriction of flexion, rotating right, and sidebending left).
• Flexion and extension: assess sidebending in both flexion and extension
  • Flex the patient's cervical spine and sidebend using translation
    • If sidebending improves (translation is easy in both directions) → flexion dysfunction
  • Extend the patient's cervical spine and assess for sidebending using translation
    • If sidebending improves (translation is easy in both directions) → extension dysfunction
• Rotation: assess using the rules of cervical motion
  • OA joint: sidebending and rotation occur in opposite directions
  • C2–C7: sidebending and rotation occur in the same direction
  • C1 (AA joint)
    • Flex the patient's cervical spine to a 45-degree angle
    • Rotate the head in both directions
    • If rotation is easier to the right compared to the left → right rotation dysfunction (C1 rotated right)
    • If rotation is easier to the left compared to the right → left rotation dysfunction (C1 rotated left)

An OA joint or C2– C7 dysfunction is named according to how the vertebra can sidebend. A C1 (AA joint) dysfunction is named according to how the vertebra can rotate.

Intersegmental motion testing

OA joint

• Position: supine
• Procedure
  1. Compare the depth of occipital sulci.
     • Place finger pads between occipital condyles and atlas.
     • Greater depth on one side indicates rotational freedom of motion to that side (e.g., if the occipital sulcus is deeper on the left, the OA is rotated to the left).
     • The sidebending component is opposite to the rotational component in all OA diagnoses (e.g., if the OA is rotated to the left, it is side bent to the right).
  2. While monitoring occipital sulci, compare depths while flexing and extending the cervical spine
     • Resolution in flexion or extension indicates freedom of motion in that position (e.g., if the occipital sulci become symmetric in flexion, the OA is flexed).

AA joint

• Position: supine
• Procedure
  1. Lock OA and C2–C7 joints
     • Flex the patient’s cervical spine (∼ 45 degrees).
  2. Compare the range of motion
     • Slowly rotate cervical spine to the right and left side.
     • A greater range of motion to one side indicates a restriction to the opposite side (e.g., if the range of motion is greater to the left, the AA is restricted to the right).

C2–C7 joints

• Position: supine
• Procedure
  1. Translate segment to the right and left side.
     • A greater translation (osteopathy) to one side indicates sidebending freedom of motion to the opposite side and rotation freedom to the opposite side (e.g., greater translation of C4 to the left indicates it is side bent right and rotated right).
  2. Translate segment in the flexed and extended position.
     • A greater translation (osteopathy) in flexion or extension indicates freedom of motion in that position (e.g., a greater translation of C6 in extension indicates it is extended).

Spurling maneuver (neck compression test)

• Function: screens for cervical radiculopathy ^[1]
• Position: sitting
• Procedure
  • Extend, sidebend, and rotate the neck toward the affected side
  • Apply downward pressure (axial loading) to the head.
• Positive test: : if the maneuver exacerbates or reproduces pain and/or paresthesia that radiates to the motor or sensory area of the affected nerve root.

Wallenberg test

• Function: : assesses vertebral artery insufficiency
• Position: supine
• Procedure
  1. Flex the neck and hold for 10 seconds.
  2. Extend the neck and hold for 10 seconds.
  3. Rotate the neck to the right and hold for 10 seconds.
  4. Rotate the neck to the left and hold for 10 seconds.
  5. Rotate the neck to the right in the extended position and hold for 10 seconds.
  6. Rotate the neck to the left in the extended position and hold for 10 seconds.
• Positive test: if the patient develops vascular or neurological symptoms (e.g., lightheadedness, visual disturbance, dizziness, or nystagmus) when performing the test

General

• The upper thoracic area and ribs usually cause suboccipital or paravertebral muscle spasms on the same side. Therefore, these areas should be treated before the cervical spine.
• Acute injuries to the cervical spine are best treated with indirect myofascial techniques or counterstrain first.
• Treatment of high cervical (OA, AA, and C2) joint dysfunctions can normalize imbalances in the autonomic nervous system, if present. The vagus nerve (CN X) exits the jugular foramen and can be affected by somatic dysfunctions of the high cervicals.

On COMLEX exams, vagus nerve dysfunction classically manifests with nausea and is an indicator to consider treating the occipitomastoid suture or the OA, AA, or C2 joints.

Vertebral artery insufficiency can be induced by cervical extension.

OA joint dysfunction

Muscle energy

• Position: supine
• Procedure
  1. Engage the restrictive barriers.
  2. Have the patient rotate or sidebend to neutral position against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage the barrier and repeat.
  5. Reassess.

High velocity, low amplitude

• Position: supine
• Procedure
  1. Position the occiput away from the restrictive barrier (reverse in all three planes of motion).
  2. Place the MCP joint of the thrusting hand at the base of the occiput.
  3. Engage the restrictive barrier (e.g., for an OA FR_LS_R dysfunction, extend the occiput slightly, sidebend to the left, and rotate to the right).
  4. Apply the HVLA thrust horizontally toward the contralateral eye (e.g., in an OA FR_LS_R dysfunction, the HVLA thrust is to the right).
  5. Reassess.

Still technique

• Position: supine
• Procedure
  1. Monitor deep sulcus.
  2. Place OA dysfunction into its freedom of motion.
  3. Add a gentle compressive force until motion is felt at the monitoring finger.
  4. Maintain compression for 3–5 seconds.
  5. While maintaining compression, guide dysfunction into its barriers.
  6. Relax.
  7. Reassess.

AA joint dysfunction

Muscle energy

• Position: supine
• Procedure
  1. Flex cervical spine to anatomical barrier (∼45 degrees).
  2. Engage rotational barrier.
  3. Have the patient rotate the neck toward its freedom of motion against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage the barrier and repeat.
  6. Reassess.

High-velocity low-amplitude

• Position: supine
• Procedure
  1. Grab the patient’s chin with the opposite hand (for an AAR_R the left hand grabs the chin)
  2. Place your index finger on the AA joint's soft tissue and the thumb on the zygomatic process (for an AARR the right index and right thumb)
  3. Ask the patient to inhale and then fully exhale: At the end of the exhalation, apply a rotational high velocity, low amplitude thrust (for an AARR a left rotational thrust).
  4. Reassess.

Still technique

• Position: supine
• Procedure
  1. Monitor deep sulcus.
  2. Place AA dysfunction into its freedom of motion.
  3. Add a gentle compressive force until motion is felt at the monitoring finger.
  4. Maintain compression for 3–5 seconds.
  5. While maintaining compression, guide dysfunction into its barriers.
  6. Relax.
  7. Reassess.

C2–C7 joint dysfunction

Muscle energy

• Position: supine
• Procedure
  1. Isolate cervical segment.
  2. Engage the restrictive barriers.
  3. Have the patient rotate or sidebend the neck toward its freedom of motion against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage the barrier and repeat.
  6. Reassess.

High-velocity low-amplitude

• Position: supine
• Procedure
  1. Perform myofascial technique.
  2. Contact the posterior articular pillar with the MCP joint and allow extension over the monitoring finger.
  3. Gently cup the chin and support the head with the opposite forearm or hand.
  4. Sidebend the head over the MCP joint.
  5. Keep the head on the midline.
  6. Rotate the head to its barrier: if this position causes dizziness, lightheadedness, pain, or any unusual symptoms, return the cervical spine to its neutral position
  7. Exert a rapid, brief rotary thrust over the MCP joint. The direction of thrust:
     • C2–C3 → opposite cheek
     • C4–C5 → perpendicular to the cervical spine
     • C6–C7 → opposite shoulder
  8. Reassess.
• Examples
  • C6 ES_RR_R (sidebending thrust)
    • Place the left hand's MCP joint on the C6 articular pillar.
    • Grab the patient's head
      • Flex the neck at the C6–C7 joint.
      • Slightly extend by anteriorly translating at C6.
    • Sidebend the neck to the left until the C6–C7 is localized.
    • Rotate the neck to the right.
    • Exert a rapid, brief sidebending thrust over the MCP joint by translating C6 to the right: the direction of thrust is toward the patient's opposite shoulder.
    • Reassess.
  • C3 FS_LR_L (rotational thrust)
    • Grab the patient’s head and flex the neck slightly.
    • Place the MCP joint of the thrusting hand on the C3 articular pillar.
    • Flex the head and neck down to C3 and apply anterior translation at C3 to induce extension
    • Rotate the head and neck towards the restrictive barrier (i.e., to the right).
    • Keep the patient’s right temple close to the table to achieve right sidebending.
    • Exert a rapid, brief right rotary thrust over the left MCP joint: the direction of thrust is toward the patient’s opposite eye.
    • Reassess.

Two types of cervical spine HVLA techniques can be used in these segments: rotational focused and sidebending focused.

Facilitated positional release (flexion or extension dysfunction)

• Position: supine with the head off the table
• Procedure
  1. Monitor dysfunction at the articular pillar of the isolated segment with the contralateral hand.
  2. Slightly flex to bring the cervical spine to neutral.
  3. Add a compressive force with the ipsilateral hand on the head.
  4. Place into freedoms (flexion or extension, sidebending, and rotation toward dysfunction).
  5. Hold for 3–5 seconds.
  6. Relax.
  7. Reassess.

Still technique

• Position: supine
• Procedure
  1. Monitor isolated posterior articular pillar.
  2. Place dysfunction into its freedom of motion.
  3. Add a gentle compressive force until motion is felt at the monitoring finger.
  4. Maintain compression for 3–5 seconds.
  5. While maintaining compression, guide dysfunction into its barriers.
  6. Relax.
  7. Reassess.

Myofascial techniques are used to treat cervical somatic dysfunctions and conditions of the fascia and muscles of the cervical region.

Cervical soft tissue release (passive)

• Position: supine
• Procedure: Apply a slow and gentle force to loosen hypertonic muscles.
  • Apply perpendicular stretch by applying traction to the cervical paraspinal muscles with fingertips.
  • Apply the parallel stretch by holding the cervical paraspinal muscles with the fingertips.

Cervical soft tissue release (active direct)

• Position: supine
• Procedures
  • Bilateral treatment
    1. Flex the neck and stabilize the shoulders by crossing your arms underneath the neck.
    2. Push the shoulders downward and further flex the cervical spine to its barrier.
    3. Ask the patient to extend the neck against your equal resistance.
    4. Relax and repeat.
    5. Apply passive stretch.
  • Unilateral treatment
    1. Have the patient rotate their head toward the affected side.
    2. Support the head with one arm crossed underneath the neck.
    3. Push the shoulder downward and further flex the neck to its barrier.
    4. Ask the patient to extend the neck against your equal resistance.
    5. Relax and repeat.
    6. Apply passive stretch.

Cervical soft tissue release (active indirect)

Uses reciprocal inhibition to relax posterior hypertonic musculature by activating anterior cervical muscles (isokinetic contraction)

• Position: supine
• Procedure
  1. Bring the patient's head gently off the table.
  2. Ask the patient to flex the neck against your isokinetic resistance.
  3. Relax and repeat.
  4. Have the patient turn their head toward the affected side for unilateral treatment.

Suboccipital soft tissue release

• Position: supine
• Procedure
  1. Place finger pads in suboccipital space.
  2. Hold and allow muscles to relax.
  3. Bring the elbows together, lean back, and apply gentle superior traction.
  4. Hold until muscles soften and a release is felt.
  5. Reassess.

Suboccipital release can normalize parasympathetic dysfunction due to the proximity of the vagus nerve (CN X) to the cervical musculature in the suboccipital region.