资料来源: 罗伯特 E.Sallis,马里兰州凯萨医疗机构,丰塔纳,加利福尼亚州美国
考试可以因为很多骨骼、 关节和韧带组成基础颈椎是脖子的一个挑战。颈椎被由七个椎骨堆放在温柔的 C 形曲线。前部的每一节脊椎骨组成的厚厚的骨感,链接到身体上方和下方的椎间盘。这些光盘帮助提供对颈椎稳定性和冲击吸收。后的脊椎,包括叶片、 横向,及棘突和关节突关节,构成了对颈脊髓和神经根的保护运河。
颈椎支持头和保护神经的元素,因为他们来从大脑和脊髓。因此,受伤或疾病影响颈部也可以影响底层的脊髓和有潜在的灾难性后果。发生在脖子上的重大议案地方颈椎损伤和退行性改变的风险增加。颈椎也是常见的神经根性疼痛肩来源。为此,颈部应评为每肩考试常规部分。
检查颈部,时,重要的是有耐心的删除足够的衣服,这样整个的脖子和肩膀上可以看到和触诊。
1.检验
2.触诊
应该做过颈脖触诊用食指和中指的提示检查压痛,肌肉痉挛或微妙的底层骨畸形。最常见做法是患者放在坐姿。应触诊的重要领域包括:
3.运动范围 (ROM)
ROM 的脖子应评估患者坐。它首先应该积极由病人或被动 (轻轻地) 如果病人是无法移动。重要的颈部运动,以评估包括:
4.强度试验
每个上述范围的议案应由考官地方反对病人的下巴和脸抵抗运动手抵抗测试。这样做的目的是为了评估疼痛或弱点。以下的议案应该抵抗进行测试:
5.寰枢轴向压缩试验 (思博的测试)
有病人旋转头偏向一侧到头顶用轴向载荷,而扭曲的脖子上,执行测试。神经根性疼痛侧肩和手臂表明颈神经根刺激。
6.向前弯曲试验
有耐心的向前 flex 与头颈部转向一边。神经根痛到同侧手臂表明对颈神经根的椎间盘撞击。
7.神经学检查
执行电动机和感官测试退出颈椎椎管的神经。损失函数可能是由于神经损伤或功能障碍有关的椎间盘突出。
8.检查以下各项:
发生在脖子上的重大议案各地颈椎损伤和退行性改变的风险增加。因此,脖子考试重点是评估这种基础结构。
颈椎被由七个椎骨堆放在温柔,前凸的 C 形曲线。这些椎骨的要素包括: 叶片、 横向和棘突和关节突关节。它们共同构成保护运河对颈脊髓和神经根。前部的每一节脊椎骨组成的厚厚的骨感,链接到身体上方和下方的椎间盘。这些光盘帮助提供对脊柱的稳定性和冲击吸收。
功能上,颈椎支持头部,并保护神经的元素,因为他们是来自大脑以及形成脊髓。因此,受伤或疾病影响颈部也可以影响底层的脊髓和有潜在的灾难性后果。在这里,我们将说明如何执行一次彻底的脖子考试,以连续的方式,来评估的稳定性和颈椎的物理状态。
让我们开始检查。你在开始之前,执行正确的手卫生。要求患者删除足够衣物,暴露出整个的脖子和肩膀上。看看从起点的头骨和上背部到脖子。应该有接近完美的对称,头部应坐在正中线。向一侧倾斜可能表明肌肉痉挛,如斜颈。
观察中线棘突和形式和大部分的棘突旁肌肉环绕中线。可能由于痉挛与创伤有关或涉及这些强大的颈部肌肉的过度使用损伤的对称。检查从外侧颈部和观察的光滑的前凸曲线。这条曲线损失通常被视为对任何种类的颈椎损伤或痛苦的非特异性反应。更富戏剧性的矫直颈椎可以看到与强直性脊柱炎。
检查后,进行触诊,应该使用食指和中指的提示检查压痛,肌肉痉挛或微妙的底层骨畸形。应触诊的重要领域包括: 棘突、 后关节面关节和触诊肌肉。
开头的棘突。开始在颅底触诊。第一个进程将感觉是 C2 椎体。然后触诊向下检查每个进程,直到你到达 C7 椎体,是最为突出的所有棘突。检查有压痛或突然一步关闭从一个进程到下一个。柔情可能挫伤或基本断裂,而下的一步可能表明骨折或韧带的破坏。
接下来,移动你的手指几厘米,左侧或右侧的每个棘突触诊后关节突关节。这些关节痛可能建议骨关节炎或骨折。最后,触诊触诊肌肉,沿两侧覆盖关节突关节的棘突。压痛或痉挛可能是由于肌肉拉伤或非自愿对来自底层的颈椎的疼痛的反应。
下一步是运动的评估的颈部范围。这可以主动或被动地。以下是一个应评估的重要动作。
首先是向前弯曲,问病人将下巴移到胸前。屈曲的正常范围是 45 ° 左右。下一步,叫病人通过一路拉他们的下巴,就像他们可以扩展他们的脖子。这项议案的正常范围是接近 55 °。随后,评估扭-指导病人第一次把他们的下巴放在肩上,然后其他和在双方之间进行比较。旋转的正常范围是在每个方向 70 ° 左右。最后,评估侧弯曲要求患者把他们的耳朵在一肩上,然后到另并在双方之间进行比较。这项议案的正常范围是 40 ° 每个方式。
运动范围测试后,让我们检讨如何评估颈部的肌肉力量。这涉及到范围的议案演习,但反对采用考官的抵抗。这样做主要是为了评估疼痛或弱点。
开始向前弯曲–问病人触摸他们在胸前,下巴,虽然你抵抗的把手放在他们的额头上。这将测试两个胸锁乳突肌。下一步,叫病人提升他们的下巴在空气中,而您提供抵抗,把手放在他们的头顶的背上。这个动作评估后路棘突旁肌肉。随后,评估所需的脖子扭,把手放在病人的下巴两侧抵抗运动的力量。这再一次计算左、 右胸锁乳突肌。最后,评估肌肉的强度涉及在身边,把手放在病人的头,抵抗运动的两侧弯曲。这将测试左、 右斜角肌。
现在让我们讨论几个执行评价异常椎间盘或骨引起的神经根撞击测试。
第一次的撞击测试叫做斯珀林的测试,也称为寰枢轴向压缩试验。有病人旋转其头偏向一侧和轴向负荷适用于头顶,而扭曲的脖子。神经根性疼痛侧肩和手臂表明颈神经根刺激。
第二是向前弯曲试验。指导病人转动他们的头上一侧,然后被动地向前弯曲他们的脖子,问他们是否他们感觉到任何疼痛。神经根痛到同侧手臂表明对颈神经根的椎间盘撞击。
脖子上考试的最后一部分涉及执行一些电机和感官测试退出颈椎椎管的神经。功能丧失的观察,在这些测试期间可能由于神经损伤或功能障碍与椎间盘突出。
通过测试的感官反应开始。向病人解释,你要轻轻触摸他们用你的指尖评价感觉变化。同时比较双方评估以下领域: 侧颈部-测试 C4 神经根、 三角肌、 上臂内侧和弯头 — — 为 C5 和 T1 的注射器,和最后的手里,专门的大拇指,中间和小指手指-分别测试径向、 正中神经和尺神经。接下来,执行某些周围的肌肉测试神经功能强度评估的演习。这包括分别为三角肌、 肱二头肌、 肱三头肌和腕屈伸肘和腕屈肌和伸肌,扩展名为屈肘弯着肘肩外展。
最后的神经测试涉及肌腱反射使用反射锤试验。若要测试肱二头肌肌腱反射,将你的拇指放在远端肱二头肌肌腱和水龙头轻快地反对它。反射的缺乏表明 C5 神经根的功能障碍。然后点击轻快地在远端肱三头肌肌腱测试肱三头肌肌腱反射。反射在这里缺乏表明 C7 神经根的功能障碍。脖子上考试到此结束。
你刚看了一个完整的脖子考试的朱庇特的示范。这种评估应与检验,以检查任何缺乏对称性,紧接着触诊,寻找温柔点或异常的步骤关闭椎骨之间开始。接下来的运动范围评估,第一次主动,然后抵抗,评估肌肉强度。随后,其中一个应该评价神经根撞击造成的异常椎间盘或骨,使用思博和向前弯曲试验。这被跟着感觉或运动的损失在颈神经根的考试。请记住,颈椎也是常见的神经根性疼痛肩来源。出于这些原因,颈部应评估每个肩膀考试的常规的一部分。一如既往,感谢您收看 !
检查颈部最好执行在坐着或站立的姿势,并应遵循了循序渐进的办法。它是重要的是有耐心删除足够的衣服,以便可以看到脖子和肩膀的表面解剖。这次考试应该从开始检查,寻找对称缺乏。这被紧接着触诊,寻找温柔点或异常的步骤关闭椎骨之间。接下来的运动范围评估,第一次主动的然后抵抗评估强度。最后,一个应该评价神经根撞击造成的异常椎间盘或骨,使用思博的和向前弯曲试验。这被跟着感觉或运动损失颈神经根中考试。
The significant motion that occurs in the neck places the cervical spine at an increased risk of injury and degenerative changes. Therefore, the neck exam focuses on assessing this underlying structure.
The cervical spine is composed of seven vertebrae stacked in a gentle, lordotic C-shaped curve. The elements of these vertebrae include: the laminae, the transverse and spinous processes, and the facet joints. Together, they form a protective canal for the cervical spinal cord and its nerve roots. The anterior part of each vertebra is made up of the thick bony body, which is linked to the body above and below by intervertebral discs. These discs help provide stability and shock absorption to the spine.
Functionally, the cervical spine supports the head, and protects the neural elements as they come from the brain and form the spinal cord. Therefore, injuries or disorders affecting the neck can also affect the underlying spinal cord and have potentially catastrophic consequences. Here, we will illustrate how to perform a thorough neck examination, in a sequential manner, to assess the stability and the physical state of the cervical spine.
Let’s start with inspection. Before you begin, perform proper hand hygiene. Request the patient to remove enough clothing so that the entire neck and upper shoulders are exposed. Look at the neck from behind starting from the base of the skull and down to the upper back. There should be near perfect symmetry and the head should sit in the midline. Tilting to one side may suggest muscle spasm, such as with torticollis.
Observe the midline spinous processes, and the form and bulk of the paraspinous muscles that surround the midline. There may be asymmetry here due to a spasm related to a trauma or due to the overuse injury involving these powerful neck muscles. Inspect the neck from the lateral side and observe the smooth lordotic curve. A loss of this curve is commonly seen as a non-specific reaction to any kind of cervical injury or pain. A more dramatic straightening of the cervical spine can be seen with ankylosing spondylitis.
After inspection, proceed to palpation, which should be done using the tips of the index and middle fingers to check for tenderness, muscle spasm, or a subtle underlying bony deformity. Important areas that should be palpated include: the spinous processes, the posterior facet joints, and the paraspinous muscles.
Begin with the spinous processes. Start palpating at the base of the skull. The first process to be felt is that of the C2 vertebra. Then palpate downwards inspecting each process until you reach the C7 vertebra, which is the most prominent of all the spinous processes. Check for tenderness or an abrupt step off from one process to the next. Tenderness may suggest a contusion or underlying fracture, while a step off may indicate a fracture or ligament disruption.
Next, move your fingers a few centimeters to the left or right of each spinous process to palpate the posterior facet joints. Tenderness over these joints may suggest osteoarthritis or a fracture. Lastly, palpate the paraspinous muscles, along either side of the spinous processes that overlie the facet joints. Tenderness or spasm can be due to muscle injury or involuntary reaction to pain coming from the underlying cervical spine.
The next step is to assess the neck’s range of motion. This can be done either actively or passively. Following are the important movements that one should evaluate.
First is forward flexion, ask the patient to move the chin to their chest. The normal range of flexion is about 45°. Next, ask the patient to extend their neck by pulling their chin all the way up as much as they can. The normal range of this motion is close to 55°. Subsequently, assess twisting – instruct the patient to first put their chin on one shoulder and then the other and compare between the sides. The normal range of rotation is about 70° in each direction. Lastly, assess side bending by asking the patient to put their ear on one shoulder, then to the other and compare between the sides. The normal range for this motion is 40° each way.
After range of motion tests, let’s review how to assess muscle strength for the neck region. This involves the range of motion maneuvers, but against resistance applied by the examiner. This is mainly done to evaluate for pain or weakness.
Starting with forward flexion – ask the patient to touch their chin to their chest, while you resist by placing your hand on their forehead. This tests both the sternocleidomastoid muscles. Next, ask the patient to raise their chin in the air while you provide resistance by placing your hand on the back of their head. This maneuver assesses the posterior paraspinous muscles. Subsequently, evaluate the strength required for neck twisting by placing your hand on either side of the patient’s chin to resist the motion. This again evaluates the left and right sternocleidomastoid muscles. Finally, assess the strength of muscles involves in side bending by placing your hand on the either side of the patient’s head to resist the movement. This tests the left and right scalene muscles.
Now lets discuss a couple of tests performed to evaluate nerve root impingement caused by abnormal disc or bone.
The first impingement test is called the Spurling’s test, also known as the Atlanto-axial compression test. Have the patient rotate their head to one side and apply an axial load to the top of head while the neck is twisted. Radicular pain to the ipsilateral shoulder and arm suggests cervical nerve root irritation.
Second is the Forward Flexion test. Instruct the patient to turn their head onto one side, then passively forward flex their neck, and ask them if they feel any pain. Radicular pain to ipsilateral arm suggests disc impingement on a cervical nerve root.
The last part of the neck exam involves performing some motor and sensory testing of the nerves exiting the cervical spinal canal. A loss of function observed during these tests could be due to nerve injury or a dysfunction related to a herniated disc.
Start by testing the sensory response. Explain to the patient that you are going to lightly touch them with your fingertips to evaluate changes in sensation. Assess the following areas, while comparing sides: lateral neck – to test the C4 nerve root, deltoid muscle, medial arm and elbow – for the C5 and T1 dermatome, and lastly the hands, specifically the thumb, middle and pinky fingers – to test the radial, median and ulnar nerves, respectively. Next, perform maneuvers assessing strength of certain surrounding muscles to test neurological functioning. This includes shoulder abduction with elbows bent for the deltoid muscle, elbow flexion for biceps, elbow extension for triceps, and wrist flexion and extension for wrist flexor and extensors, respectively.
The last of the neurological tests involve testing tendon reflexes using a reflex hammer. To test Biceps tendon reflex, place your thumb over the distal biceps tendon and tap briskly against it. Lack of reflex suggests dysfunction of the C5 nerve root. Then tap briskly over the distal triceps tendon to test the triceps tendon reflex. Lack of reflex here suggests dysfunction of the C7 nerve root. This concludes the neck exam.
You’ve just watched JoVE’s demonstration of a complete neck exam. This assessment should begin with inspection to check for any lack of symmetry, followed by palpation, looking for tender spots or an abnormal step off between the vertebrae. Next, range of motion is assessed, first actively and then against resistance to assess muscle strength. Subsequently, one should evaluate for nerve root impingement caused by abnormal disc or bone, using the Spurling’s and the Forward Flexion test. This is followed by the examination for sensory or motor loss in the cervical nerve roots. Remember, the cervical spine is also a common source of radicular pain in the shoulder. For these reasons, the neck should be evaluated as a routine part of every shoulder exam. As always, thanks for watching!
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