6.3 Cervical & Thoracic Spine Assessment

PA8 task 0202 at the cervical and thoracic spine starts with a safety question: is this neck stable enough to special-test? An axial-load, midline-tender, neurologically dirty cervical spine is a Domain III emergency, not a Spurling station. Once the neck is cleared, you cluster radiculopathy tests, hunt myelopathy, and remember that left-shoulder pain is sometimes a spleen.

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Imaging Rules After Trauma: Canadian C-Spine versus NEXUS

Both rules try to find alert, stable blunt-trauma patients who do not need cervical imaging. Neither rule applies to a patient who is unconscious, hypotensive, already paralyzed, or too young for the derivation cohort without extra caution. On the field, when in doubt, immobilize.

NEXUS (National Emergency X-Radiography Utilization Study): imaging is not required only if all five low-risk criteria are present:

1. No posterior midline cervical tenderness
2. No evidence of intoxication
3. Normal alertness (GCS 15)
4. No focal neurologic deficit
5. No painful distracting injury

If any item fails, you cannot NEXUS-clear. Midline tenderness alone blocks clearance. Intoxication and 'distracting injury' are judgment calls—and that is a known weakness of the rule.

Canadian C-spine Rule (CCR) is a three-step instrument (Stiell et al., 2001; head-to-head with NEXUS in NEJM 2003, where CCR sensitivity was 99.4% versus 90.7% for NEXUS in that cohort):

1. Any high-risk factor that mandates imaging? Age ≥65, dangerous mechanism, or paresthesias in the extremities. Dangerous mechanism includes fall from ≥3 feet or 5 stairs, axial load to the head (diving/spearing), MVC >100 km/h, rollover, ejection, motorized recreational vehicle, or bicycle collision. Any yes → image.
2. Any low-risk factor that allows safe ROM assessment? Simple rear-end MVC, sitting in the ED, ambulatory at any time, delayed-onset neck pain, or absence of midline tenderness. If no low-risk factor is present, you cannot safely assess motion → image.
3. Able to actively rotate 45° left and right? If yes, imaging is not recommended by the rule. If no, image.

CCR can still image someone without midline tenderness if the mechanism is dangerous or they cannot rotate 45°. NEXUS cannot clear anyone with midline tenderness. CCR is not for age <16 in the original rule; NEXUS has no age cutoff but loses performance in older adults. Pregnant patients, known vertebral disease, and prior C-spine surgery are populations where you should not force either rule.

Exam trap: performing Spurling (extension, ipsilateral side-bending/rotation, then axial compression) on an acute unstable neck. Spurling is a radiculopathy test for a stable exam. It is contraindicated in suspected fracture/instability, rheumatoid instability, cancer, or infection. If CCR/NEXUS says image, you immobilize and image—you do not compress the head to 'see if it is a stinger.'

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Stingers, Radiculopathy, and Myelopathy

Stinger/burner

A stinger (burner) is a transient unilateral upper-trunk brachial plexus or cervical-root neurapraxia. Mechanisms:

• Traction: shoulder depressed, neck side-bent away (classic tackle).
• Compression: neck extension and side-bending toward the painful arm, pinching the foramen (older athletes with foraminal stenosis).
• Direct blow to the Erb point.

Symptoms are burning, electric pain, and often C5–C6 weakness (deltoid, biceps, spinati) in one arm, lasting seconds to minutes. Return only when the athlete is fully asymptomatic with full cervical ROM, full strength, and normal sensation. Hold out, immobilize, and treat as a cord injury when symptoms are bilateral, involve the legs, are recurrent, last, or come with neck pain or incomplete ROM. Bilateral 'stingers' are not stingers.

Cervical radiculopathy cluster (Wainner)

No single test diagnoses a pinched cervical root. Wainner and colleagues (2003) described a four-item cluster:

In the original CPR, 4/4 positives pushed post-test probability to about 90%; 3/4 to about 65%; 2/4 was only modestly helpful. Independent validation has been in the same direction: more positives, more confidence. Still a cluster, still not an MRI. Pair with dermatomes, myotomes, and reflexes.

Myelopathy

Cervical myelopathy is cord compression, not a single root. Look for Hoffmann (flicking the middle fingernail produces thumb-index flexion), hyperreflexia, clonus, inverted supinator, clumsy hands, and a wide-based or unsteady gait. Hoffmann is a clue, not a stand-alone MRI order—unilateral Hoffmann in isolation is weak; the cluster of upper-motor findings plus gait/hand clumsiness is what moves you. Progressive myelopathy, bowel/bladder change, or a stepwise neuro decline is a red-flag referral, not a trial of cervical traction.

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Thoracic Outlet, First Rib, Chest Wall, and Kehr

TOS versus cervical rib: TOS is positional compression of the brachial plexus and/or subclavian vessels in the scalene triangle, costoclavicular space, or under pectoralis minor. Adson, Wright, and Roos are poorly specific; many healthy athletes lose a pulse. Need a history of positional neurovascular symptoms. A cervical rib is a congenital extra rib that can narrow the outlet—consider it when TOS symptoms are structural, not when one Adson is noisy. An elevated first rib can mimic TOS with root-of-neck pain and restricted first-rib springing; treat it as a mechanical finding, not an automatic vascular emergency.

Rib fracture versus costochondritis: traumatic, focal bony pain and a positive rib-compression test versus insidious, tender chondral junctions without a blow. A rib fracture with respiratory distress or flail chest is emergency care. Costochondritis is a pain diagnosis of exclusion after you have thought about cardiac and visceral causes.

Kehr sign: left-shoulder pain referred from diaphragmatic irritation, classically a ruptured spleen (blood under the left hemidiaphragm, C3–C5 phrenic). After a left-flank or left-upper-quadrant blow, left-shoulder pain is not automatically AC joint. Look for abdominal rigidity, shock, and Kehr; that athlete belongs in an emergency referral, not an AC special-test cluster.

Red flags you do not 'treat through'

• Progressive neurologic deficit (worsening myotome, expanding sensory loss, emerging myelopathy)
• Bowel or bladder dysfunction or saddle symptoms (cord/cauda-level emergency—more lumbar, still a spine emergency)
• Night pain, unexplained weight loss, history of cancer (tumor until you have a workup)
• Fever, IV drug use, or immunosuppression (infection/epidural abscess)
• Trauma that fails CCR/NEXUS, or any suspicion of unstable C-spine

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Worked Scenario: Rugby Player with a Stinger

A rugby flanker makes a tackle. The head is side-bent away as the shoulder is hit—traction mechanism. He comes off with burning down the right arm only. At 90 seconds the burning is gone. Cervical spine: no midline tenderness, full active rotation past 45° both ways, no bilateral symptoms, no leg symptoms, GCS 15, not intoxicated. Strength returns to 5/5 in deltoid and biceps; sensation is intact. This is a classic unilateral, resolved stinger. He may return only when fully asymptomatic with full ROM and strength—which, in this vignette, he now is. Document it. Recurrent stingers the same season still warrant imaging and a longer hold.

Change three facts and the plan reverses. Bilateral burning, leftover weakness, or midline tenderness after an axial load means you do not Spurling, you do not send him back, and you apply CCR/NEXUS logic: dangerous mechanism + paresthesias = image; NEXUS already fails if there is a deficit or midline tenderness. Immobilize and treat as an unstable C-spine / cord until imaging says otherwise.

Exam trap: Spurling an acute, possibly unstable neck 'to confirm a stinger,' or returning a player with bilateral symptoms because 'stingers are common in rugby.'