University for Development Studies, SMHS

Student guide examination of the neck, block 2.2 Medicine

Student guide Examination of the Neck: block 2.2

Applied anatomy:
The neck consists of the area between the occipital bone and vertebra T1.
The neck consists of the following clinical important structures:
· bony parts: the cervical vertebrae and the intervertebral discs. The scapulae and the clavicular
bones can also be considered as part of the neck.
· ligaments: between the anterior and posterior vertebrae and between the lamina of two
adjacent vertebrae
· muscles
· vessels
· nerves
· lymphnodes

Cervical vertebrae:
There are seven cervical vertebrae( C1-C7). The neck is part of the spine, which further comprises of the
thoracic (T1-T12), the lumbar (L1-L5). the sacral vertebrae (S1-S5) and the os coccyges. The spine in total
is a very important structure in body posture. The cervical part of the spine is much more mobile than
the rest of the spine.

Picture 1: the curvature of the spine.

Note that the cervical part of the spine
has a slight lordosis, whereas the thoracic
part of the spine has a slight kyphosisis.
(Bates)

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

Picture 2 and 3: anatomy of the cervical vertebrae. (Bates)

The cervical vertebrae have a characteristic opening in the transverse processes (foramen
ransversarium) through which the vertebral artery runs, except for C7. The spinous processes are
placed more or less horizontally.
The first cervical vertebra, the atlas, contains neither a vertebral body nor a spinous process. This
vertebra consists of 2 lateral parts (lateral mass) that are connected by a short anterior arch
and a long posterior arch. The anterior arch has a joint facet (fovea dentis) at the back for the ‘tooth’ of
C2 (dens). The transverse processes protrude significantly laterally and are reasonably accessible for
palpation.
The second cervical vertebra, the axis, has a cranially protruding tooth (dens). The dens articulates with
the anterior arch of the atlas. The atlas and the occipital bone form the left and right atlanto-occipital
joints (C0-C1); the atlas and the axis form the lateral atlanto-axial and median atlanto-axial joints (C1-
C2). The transverse ligament of the atlas is one of the ligaments that keep the dens in position.
The alar ligaments function as a type of cruciate ligament on either side of the dens axis. They connect
the dens with the inner side of the occipital condyle (= joint facets for the atlanto-occipital joints).
The upper ridges of the vertebral bodies of C3-C7 have upright side edges, the uncinate processes.
Because of this, the bodies of these vertebrae link with each other (joints of Luschka). These joints act as
synovial joints. The 7th cervical vertebra is called the vertebra prominens, because its spinous process is
longer than those of the other cervical vertebrae – it is very easily accessible for palpation.

Muscles of the neck

Clinically relevant muscles in the cervical region are the splenius capitis and splenius cervicis muscle, the
semispinalis capitis and semispinalis cervicis muscle, the levator scapulae muscle, the
sternocleidomastoid muscle, the scalene muscles and the descending part of the trapezius muscle.
(see e.g. Gray’s anatomy, Chapter 7).

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

· splenius capitis muscle:

origin: lower part of nuchal ligament, spinous processes C7 and T1-T4
insertion: superior nuchal line and mastoid process
action: unilateral contraction flexes and rotates the head unilaterally. Bilateral contraction
extends the neck
action: extension, rotation and lateral flexion of the head.
· splenius cervicis muscle:
origin: spinous processes T3-T6.
insertion: transverse processes C1-C3.
action: unilateral contraction results in lateral flexion and rotation of the head. Bilateral
contraction results in extension.
· semispinalis capitis muscle
origin: transverse processes C4-C7 and articular processes C4-C6
insertion: between superior nuchal line and inferior nuchal line.
action: extension of the neck
· semispinalis cervicis muscle
origin: transverse processes T1-T6.
insertion: spinous processes C2-C5
action: prime mover for head extension. Also lateral flexion and rotation
· levator scapulae muscle
origin: transverse processes C1-C4.
insertion: superior angle of scapula
action: elevates and rotates the scapulae
· sternocleidomastoid muscle:
origin: manubrium of sternum and sternal extremity of clavicle (2-headed)
insertion: mastoid process and superior nuchal line
action: unilateral contraction results in ipsilateral lateral flexion and rotation. Bilateral
contraction flexes the neck and lifts the sternum and assists in forced inspiration.
· descending part of the trapezius muscle:
origin: superior nuchal line, external occipital protuberance and nuchal ligament
insertion: acromion/ lateral part of clavicle
action: elevates the shoulder

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

· anterior scalene muscle:

origin: anterior tubercle of the transverse process C3-C6
insertion: first rib
action: lifts the first rib during inhalation and rotates the head
· middle scalene muscle:
origin: transverse process C2 and between the anterior and posterior tubercle of the transverse
processes C3-C7
insertion: first rib
action: flexes the neck laterally and lifts the first rib in deep inhalation
· posterior scalene muscle (this muscle can sometimes be absent and then makes part of the
middle scalene muscle)
origin: posterior tubercle of the transverse processes C4-C6
insertion: second rib
action: flexes the neck laterally and elevates the second rib during deep inhalation

Surface anatomy:

Picture: 4: surface anatomy of the neck

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

The anterior region of the neck:

Has several palpable landmarks, including the larynx, trachea and sternal notch.
The larynx is found in the middle of the neck and is composed of multiple cartilages
· thyroid cartilage
· “Adam’s apple”
· Inferior to the larynx are the cricoid cartilage and trachea.
Terminates at the sternal (jugular) notch of the manubrium and the left and right clavicles.

The nuchal region:

The posterior neck region. It houses the spinal cord, cervical vertebrae and associated structures.
The bump at the lower boundary of this region is the vertebra Prominens (C7).
Superiorly along the midline of the neck, is the ligamentum nuchae, a thick ligament that runs from C7
to the nuchal lines of the skull.

The lateral part of the neck contains the sternocleidomastoid muscles which partitions the neck into two
clinically important triangles, an anterior triangle and a posterior triangle. Each triangle houses
important structures that run through the neck.

The anterior triangle:

The anterior triangle lies anterior to the sternocleidomastoid muscle and inferior to the mandible. It can
be further subdivided into four smaller triangles:
· Submental triangle: most superior. It lies inferior to the chin in the midline of the neck. It is
partially bounded by the anterior belly of the digastrics muscle and contains some cervical
lymph nodes and tiny veins.
· Submandibular triangle: Inferior to the mandible and lateral to the submental
triangle. It is bounded by the mandible and the bellies of the digastric muscle.
· Carotid triangle: is bounded by the sternocleidomastoid, the omohyoid and the posterior
digastrics muscles. The common carotid artery can be palpated here and it also contains the
internal jugular vein as well as some cervical lymph nodes.
· Muscular triangle: it is the most inferior of the four triangles. It contains the sternohyoid and
sternothyroid muscles, as well as the lateral edges of the larynx and the thyroid gland. It also
contains some cervical lymph nodes, which are present throughout the neck.

The posterior triangle:

Is located at the lateral region of the neck and it is posterior to the sternocleidomastoid muscle, superior
to the clavicle and anterior to the trapezius muscle.
It is subdivided into two smaller triangles:
· the occipital triangle: this one is larger and more posterior placed. It is bounded by the
omohyoid, trapezius and the sternocleidomastoid muscles. It contains the external jugular vein,
the accessory nerve, the brachial plexus and some lymph nodes.
· supraclavicular triangle: bounded by the clavicle, the omohyoid and the sternocleidomastoid
muscles. It contains part of the subclavian vein and artery as well as lymphnodes

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

Picture 5: Anterolateral view of head and neck.

In the neck, the Platysma when contracted throws the skin into oblique ridges parallel with
the fasciculi of the muscle. The Sternocleidomastoideus has the most important influence on
the surface form of the neck (Figs. 1194, 1195). When the muscle is at rest its anterior border
forms an oblique rounded edge ending below in the sharp outline of the sternal head; the
posterior border is only distinct for about 2 or 3 cm. above the middle of the clavicle. During
contraction, the sternal head stands out as a sharply defined ridge, while the clavicular head
is flatter and less prominent; between the two heads is a slight depression: the fleshy middle
portion of the muscle appears as an oblique elevation with a thick, rounded, anterior border,
best marked in its lower part. The sternal heads of the two muscles are separated by a V-
shaped depression, in which are the Sternohyoideus and Sternothyreoideus.
Above the hyoid bone, near the middle line, the anterior belly of the Digastricus produces a
slight convexity.
The anterior border of the Trapezius presents as a faint ridge running from the superior
nuchal line, downward and forward to the junction of the intermediate and lateral thirds of
the clavicle. Between the Sternocleidomastoideus and the Trapezius is the posterior triangle
of the neck, the lower part of which appears as a shallow concavity—the supraclavicular
fossa. In this fossa, the inferior belly of the Omohyoideus, when in action, presents as a
rounded cord-like elevation a little above, and almost parallel to, the clavicle.

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

Picture 6: Front view of neck.

Examination of the neck:

To be able to examine the neck of a patient, the patient should have his whole upper body exposed. For
female patients, the bra is allowed to stay on.

1. Inspection
On inspection, identify the following landmarks:
· The upper boarder of the neck: consisting of the inferior part of the mandible, the mastoid
process and the occipital protuberance of the occipital bone
· The lower boarder of the neck: consisting of the upper part of the scapulae, the upper part
of the clavicle, the manubrium (upper part of the sternum) and the vertebra C7
· Spinous processes: especially C7 (also T1) is very prominent
· Two superficial muscles of the neck: platysma and the sternocleidomastoid muscle
· Note the curvature of the neck (slight kyphosis is normal)
· Note the position of the neck in relationship with the rest of the spine and the shoulders
· Look for lumbs and swellings
· Assess the muscle bulk and symmetry

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

· Look for scars

Picture 3: shows the platysma. Inserts Picture 4: the sternocleidomastoid muscle: runs anteromedially
at the mandible and at the fascia of from the mastoid and splits; forming a sterna head (inserts on the
the pectoral and the deltoid muscle. sternum) and a clavicular (cleido-) head (inserts on the clavicle).
Innervated by CN VII Innervated by C2-C3 and CN XI. Acting singly, the
sternocleidomastoid muscle tilts the head to the ipsilateral side,
laterally bending of the nack and rotationg the face. Acting
together they flex the neck

The neck can be divided in the anterior triangle and the posterior triangle. They are separated by the
sternomastoid bulk of the sternocleidomastoid muscle. Ask the patient to rotate their head to
differentiate between the two.
Ask the patient to extend the neck to visualize the cricoids and the thyroid cartilage.
Ask the patient to grin to see the platysma.

2. Palpation

Palpate the patient preferably in standing or sitting position and as the examiner, stand behind the
patient.
Pay attention to:
· Pain: compare left and right
· Swellings and its characteristics
· Muscle tone (with the palpating fingers placed transverse to the course of the fibres)
· abnormal structures
· discontinuity
· symmetry
The following bones and soft tissues are accessible for palpation:
cervical vertebrae:
- external occipital protuberance and cervical spinous processes (of C2 and the vertebrae in the caudal
direction) (during which the forehead rests against the examiner’s hand); Indication of pain upon
pressure on a spinous process (or by pushing it a bit to the left or right) can mean a disorder of the

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

segment in question. Note that it is sometimes not possible to palpate the spinous processes of C3 and
C4 due to a large overlying spinous process of C2.
The larger bundles of the cervicobrachial plexus can be palpated (carefully) on either side of the bony
cervical spine.
- skin
- paravertebral cervical musculature and trapezius muscle (descending part) (hypertonia)
- muscle attachments of the occipital bone (from the external occipital protuberance to the mastoid
process bilaterally) (tendoperiostitis or disorder of the major or minor occipital muscle)
NB: Bear in mind NOT to palpate SIMULTANEOUSLY on BOTH SIDES in the carotid triangle.

3. Active movement
For the movements of the head in relation to the spine the atlanto-occipitalis joint and the lateral
atlanto-axial joint and median atlanto-axial joint form an important link. The possible movements in the
atlanto-occipital joint are flexion and extension. The movements that are possible between the atlas and
axis are rotation, flexion, extension and limited lateroflexion. Between the joints of C2 up to and
including C7 the following movements, though limited, are possible: lateroflexion, rotation, flexion and
extension. Lateroflexion and rotation are not possible independently of each other due to the position
of the facet joints; the uncovertebral joints accompany all movements.

During active movement you will instruct the patient to move the head in a certain way to their
maximum. Stimulate them to really go to the maximum although there might be pain. Demonstrate the
movements yourself if the patient does not understand you well.

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 University for Development Studies, SMHS
Student guide examination of the neck, block 2.2 Medicine

During the examination, note the following:

· the course of the movement (fixations?)
· the painful section of the movement trajectory?, is the erector muscle of the spine tensed
symmetrically?)
· the maximum movement trajectory
· the appearance of pain
· the appearance of crepitations
· observing contractures and/or compensatory movements

The following movements of the head in relation to C7 are possible:

· flexion: approximately 85º (of which 10º in the atlanto-occipital joint and 30º in the atlanto-axial
joint); primary sternocleidomastoid aided by middle scalene and the deep muscles in the front of
the neck
· extension: approximately 55º (of which 20º in the atlanto-occipital joint); trapezius, splenius capitis
and cervicis and the semispinalis muscle. They are aided by the intrinsic neck muscles
· lateroflexion: approximately 35° in both directions (note: more if you allow the patient to rotate the
head slightly); mainly trapezius, levator scapulae and scalene muscle
· rotation: approximately 85º in both directions (of which 35º in the atlanto-axial joint); primarily the
sternocleidomastoid, aided by scalene and both splenius capitis and cervices muscles

4. Passive movement

The passive range of motion examination of the spine is not a standard procedure, because there is
a risk of causing damage when (incompetently) conducting a passive range of motion examination of the
spine
This examination can be best performed by having the patient sit on a chair and the examiner stand
behind the patient.
The examiner should holds the head of the patient with both hands (palms of the hands covering the
ears, thumbs on the cheekbones) and ‘rolls’ it gently (combination of lateroflexion and axial rotation in
the cervical spine) to the left and right.
Generally speaking, conduct the passive movements in such a manner that you hold the patient’s head
firmly with both hands and move your arms and shoulders as little as possible. The examiner should
make their movements from the torso and pelvis. If this movement causes (a lot of) pain and resistance
is felt against this movement, then the passive range of motion examination should NOT be continued,
and only careful superficial palpation should take place. If this examination is tolerated, you can
continue with testing the specific movements of the neck separately. Note the maximum rate of
movement and pain.
Move the head in anteflexion, during which the head is pulled lightly. Ensure that the anteflexion takes
place in the low cervical region (‘chin on chest’).
Move the head in anteflexion, but now try to allow the anteflexion to take place in the high cervical
region, by carefully moving the chin in the direction of the larynx. During this, palpate with an index

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Student guide examination of the neck, block 2.2 Medicine

finger the spinous process of C2. Note that the distance between the spinous process of C2 and the
occipital bone increases.
The examiner holds the head with both hands (palms of the hands on the ears, thumbs on the
cheekbones). The head is again rolled carefully to the left and right across the table a number of times
(lateroflexion in combination with axial rotation in the cervical spine). Ask if there is any pain and
localise the painful location using your index fingers (high, middle or low in the cervical spine). If this
movement is possible and the patient does not indicate any severe pain, and there is no strong
resistance against movement either, the passive range of motion examination can be continued. The
handling procedure described above is always the starting point.

Pain that is the same during active and passive movement is likely to be originated from a bony
structure, a nerve, a bursa etc.
Pain that is much worse or only present during active movement, but not at passive movement, is likely
to originate from the muscles.

Sources (also recommended for further reading):

Bates Guide to Physical Examination
Boumans et al. The examination of the spine. 2003
Gray’s Anatomy
http://www.theodora.com/anatomy/surface_anatomy_and_surface_markings.html

First version by dr. Femke Matorwmasen, 13-11-2011

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