The pediatric cervical spine can be difficult to palpate, and seem a bit overwhelming if you are not familiar or experienced with touching such a tiny area. However, if you know what you are looking for, it's as easy as 1-2-3.

The concepts described in this column are based upon the dynamic chiropractic paradigm and the work of Dr. Henri Gillet and Dr. L. John Faye. Rather than concentrating on the gross movements of the spine, it will focus on the specific joint movements at each cervical level.

The major objective of dynamic palpation is to distinguish normal from abnormal vertebral segmental motion. This includes the discovery of any joint fixations, i.e., motion restrictions versus smooth gliding.

In motion palpation, each individual motion unit is palpated in all of its ranges of motion respectively. Segmental motion studies, which identify dysfunctional motor units and asymmetric behavior such as described here, should not be confused with gross motion studies.

The spine has three distinct types of movement: active, passive, and joint play. In checking the dynamic movement of the spine, we will be accessing this small but distinct accessory movement within the synovial joint, called joint play.

Joint play is the degree of end movement felt passively that cannot be achieved though voluntary movement. Proper joint play should exist in all ranges of motion that are normal for that joint, for example extension, lateral flexion and rotation.

The loss of joint play can result in secondary muscle spasm, which is often accompanied by pain. Loss of joint play is often felt as a firm "bulge" or hard end feel at the limit of the motion being tested. Loss of joint play (hypomobility) at one spinal level often results in compensatory excess movement (hypermobility) at other adjacent levels.

There exist three types of fixations in the spine: muscular, ligamentous, and articular -- each with distinct individual characteristics.

Muscular fixations (type I) represent the state of a muscle or muscles that fixate vertebrae and hinder normal movement. They are the most numerous in number and the type of fixation most often found in children. Of the three types of fixation, they are usually secondary or compensatory in nature. They are palpated as taut and tender, with a rubbery end feel.

Ligamentous (type II) fixations are the result of chronically fixated joints resulting in ligamentous shortening, and are palpated with a hard abrupt end feel in any particular direction.

Type III or articular fixations are palpated as completely immobile in all directions and are considered total fixations. In the latter stages this will progress to ankylosis.

The cervical spine has been made to adapt to the weight bearing of the head and the enlarged spinal cord in this region. To accommodate for the cervical lordosis, the IVDs are broader in the anterior than the posterior. The head rests on the occipitoatlantal joints.

The basic movements of the cervical spine are flexion, extension, rotation, and lateral flexion. There also exists a coupling movement in several ranges of motion, which restricts some motions and enhances others.

Specific areas in the cervical spine concentrate certain movements. For example, approximately 50% of the flexion/extension component occurs at the occipitoatlantal joints, with the remaining half distributed among the remaining cervical joints.(1)

This movement normally occurs prior to any lower cervical involvement. The neck can be moved about 10 degrees in flexion between occiput and atlas, and extended for about 15 degrees without participation of any other cervical vertebra. Lateral flexion in the cervical spine is performed by unilateral contraction of the neck flexor and extensor muscles. Occipital rotation takes place initially as one unit of the occipital condyles on the axis.

During normal rotatory movement of the atlanto-axial joint, the occiput and the atlas move together about the odontoid process. Approximately half of the active rotation in the cervical spine takes place at the atlanto-axial joints about the odontoid process. After about 30 degrees of atlas rotation on the dens, the body of the axis begins to rotate, followed by progressively diminishing rotation in the remaining cervical segments.(2)

Between C3 and C7, the articular processes are almost flat, and thus freely moveable. They are found at the junction of the laminae and pedicles. The maximum A-P and P-A movement in the cervicals usually takes place at the C4/C5 level. It is also important to note that coupling of cervical rotation and lateral flexion takes place, varying with the segmental level. Cervical vertebrae from C2-C7 move in flexion, extension, rotation and lateral flexion.

Palpation of the cervical spine may seem complicated, but is actually quite is simple. One important point to remember when palpating the newborn is that at a young age the mastoid process is rudimentary.

This is important because, typically people locate the atlas TP by finding the mastoid process and moving inferior and slightly anterior. However, in the case of the newborn, you may think you are on mastoid but (because the mastoid is rudimentary) really be on the atlas TP, thus when you use this landmark to find the atlas, you end up on C2 or C3.

The pediatric patient will be palpated in an upright position. Depending upon the age of the child, this position may need to be supported or unsupported by the practitioner or parent.

Beginning at the Occipital-Atlantal junction, to check rotation of the occiput on atlas, place one finger tip on the transverse process (TP) of the child's atlas and slowly rotate the patients head to one side and than the other. Repeat on the contralateral TP feeling for the TP to glide behind the mandible upon full rotation.

Be patient in developing your palpatory skills, as this motion can be difficult to feel particularly on young children. Although this is usually not as significant a problem in young children, the bulging of the sternocleidomastoideus (SCM) can make this palpation additionally challenging.

To palpate flexion-extension of the occiput on atlas, place your finger between the lateral tip of the atlas TP and the ramus of the jaw. Cup the crown of the patient's head with your stabilization hand and gently push A-P in a gliding motion pushing the chin forward. Then, move the patient's head in the opposite motion bringing the child's chin inward against the throat. If there is no fixation present, you should feel that space subtly opening and closing.

Lateral flexion of the occiput on atlas can be measured by placing your palpating finger over the atlas TP and the stabilizing hand on the vertex of the skull. Flex the crown laterally from side to side feeling for the space above the transverse process to open and close. Be sure to localize the motion (avoiding mid-cervical movement) by using the palpating finger as a fulcrum.

The occiput and the axis (C2) are not adjacent to one another thus they are unable to articulate, but they do combine into a functional unit by ligaments, deep cervical muscles, and fascia. The occipital condyles, atlas and axis form a ball-and-socket type joint where flexion, extension, slight lateral flexion and rotation can be demonstrated as previously described.

All cervical vertebrae from C2-C7 participate in the movements of flexion, extension, lateral flexion and rotation to varied degrees. To evaluate the mid- and lower cervicals in lateral bending, place your palpating finger against the posterolateral aspect of the spinous process, and tilt the head in lateral flexion with the supporting hand. Your palpating finger will once again serve as a fulcrum, while checking for joint play at the end of passive movement.

To test for P-A movement, place your middle finger (palpating finger) on the articular pillar of the joint being examined, and your stabilization hand cupping the patient's forehead. Fully extend the patient's neck utilizing the palpating finger as a fulcrum at each level. Joint play should be tested at each level by applying digital pressure with your finger. Separation of the spinal process should also be noted on A-P and P-A movement.

Although most chiropractors are familiar with testing P-A movement, A-P motion is often overlooked. A-P movement can be tested by placing the pad of your palpating finger on the anterolateral surface of the TP of each level. Joint play is tested by flexing the patient's neck and pulling the SCM muscle slightly back and lateral. Be gentle with this palpation, as it is often very tender.

The last movement in the cervical spine to test, is P-A rotation of C2-C7. To evaluate this movement, place your palpating finger on the posterior aspect of the patient's neck while rotating the head with the stabilization hand. Place your palpating finger between the TPs or on the lamina, checking for joint play at the end of passive movement. Posterior rotation can also be tested using a similar technique however it is very sensitive and not commonly fixated in children.

The joints of Lushka (or uncovertebral joints) of the cervical spine are located on the anterolateral surfaces of the vertebral body and guide the coupled motion of rotation and lateral flexion, limiting side bending. These joints begin to develop between six and nine years of age and are complete at age 18. Whether these joints are truly synovial joints is highly disputed, as they are not found in a large percentage of the population.

The cervical spine is an area of great importance and mastery of this palpation will assist in your evaluation of the pediatric patient. No matter which spinal analysis and adjusting technique you utilize in your practice, clinical competence and confidence in palpation will assist you in detecting subluxation in the child.

Reference

Schafer, RC, D.C. and Faye, LJ, D.C.: "Motion Palpation and Chiropractic Technic," Huntington Beach, CA, The Motion Palpation Institute, 1989, pp 79-111.