Upper Cervical Flexion Test | Transverse Ligament Assessment

Upper cervical spine instability has a prevalence rate of 0.6% according to Beck et al. (2004) and is associated with inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis, as well as trauma and congenital deviations such as Down’s syndrome or Marfan’s disease. In order to safely apply manual therapy techniques to the cervical area, it is necessary to screen for possible upper cervical instability.

According to Cattrysse et al. in the year 1997, the upper cervical flexion test has an intra-rater reliability of -0.27 to 1, so poor to perfect, and an inter-rater reliability of Kappa 0.64 to 1, which is substantial to perfect. However, this test has not been evaluated by diagnostic studies, which is why we are giving it a questionable clinical value.

In order to perform the test, have your patient in supine position and stand at the head of the bench. Fixate vertebrae C3 with a key grip into ventrocranial direction. Place your other hand high on the occiput and fixate your patient’s forehead with your shoulder or chest. Now perform a gentle flexion movement.

This test is positive if your patient reports symptoms of dura compression, which is diffuse pain on several segments of the upper back and head, or spinal cord compression, which indicates a tear of the transverse ligament.

The fixation of C3 is different from the common literature which describes a fixation of C2. The problem with a fixation of C2 is that we are preventing the dens of C2 from tilting backward and thus from pinching the dura mater or the myelum. The Upper Cervical Flexion test, however, is a provocation test. By performing an upper cervical nod, the condyles of C0 roll forwards and slide backward taking the very mobile atlas/C1 with them in posterior direction. When the anterior arch of the atlas impacts the dens, the dens of C2 is tilted backward. This backward tilt and translation can be excessive in case of a torn transverse ligament, possibly pinching the dura mater or the myelum. As a side-note, the backward tilt of the dens of C2, in turn, causes an extension movement of C2 on C3. The exact opposite movement occurs with upper cervical extension. In this case, an intact transverse ligament will tilt the dens of C2 anteriorly, causing a flexion movement between C2 on C3.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Other orthopedic tests to assess upper cervical instability are:

• Transverse Ligament Test / Anterior Shear Test
• Sharp Purser Test
• Alar Ligament Stress Test
• Lateral Shear Test / Lateral Displacement Test

Cattrysse E, Swinkels RA, Oostendorp RA, Duquet W. Upper cervical instability: are clinical tests reliable?. Manual Therapy. 1997 May 1;2(2):91-7.