The Fifth Cervical Vertebrae, abbreviated C5, is one of seven vertebral segments to comprise the Cervical Spine . C3 , C4 , C5 and C6 are often grouped together due to their similar structural characteristics. While their bony structures resemble each other, their Nerve Root innervation, Pain presentation and treatment protocols are distinct. This page details the structure of this vertebral segment, its function as an extensive attachment site and the nerves it gives rise to.
The rectangular bodies of C3-6 are wider laterally than they are in an anteroposterior direction with a concavity to their inferior and superior surfaces that is generally flatter in other vertebrae (SOURCE-4). The surfaces are less comparable at their margins where on the superior surface they raise posterior-lateral hooks known asUncinate Processesand on the inferior surface the anterior and posterior margins are exacerbated (SOURCE-5). The Uncinate Processes are congruent with the superior vertebrae (C3- C7 ), forming smallUncovertebral Joints(SOURCE-5). When these joints are damaged, this can be relayed onto the intervening outer rings (annuli) of the Intervertebral Discs (SOURCE-5).
The C3- C6 Pediclesare shorter, typically curved in a posterolateral direction and extend thinLaminaeposteromedially which form the lateral walls of theVertebral Foramen(orVertebral Canal) (SOURCE-5). This triangular canal facilitates the passage of the Spinal Cord which is particualry thick in the Cervical Spine due to the addition of the Cervical Plexus and Brachial Plexus (SOURCE-4). The lateral walls of the canal meet posteriorly at theSpinous Processwhich for C-3-6 are short and bifid (SOURCE-5).
Between C3- C6 corresponding superior and inferior articular processes from adjacent vertebrae meet at Zygapophyseal Joints (orFacet Joints). Collectively the C3-C6 vertebrae and the intervening Facet Joints form theArticular Pillar, a column-like structure whose orientation and architechture provide the Cervical Spine with stability while permitting significant Range of Motion .
TheTransverse Processesin this region are short lateral extensions that give offAnterior and Posterior Tubercleswhich are unique to the Cervical Spine and serve as attachment sites (SOURCE-5).
Compared with other vertebrae of the Cervical Spine , C3-6 have (SOURCE-4+5):
Spinous Process- short and bifid, so short certain muscles such as the Trapezius and Splenius Capitis attach to Nuchal Ligament rather than vertebrae
Body- smallest typical vertebrae in Vertebral Column . Broader side to side, than front to back
Laminae- narrow and thin. Forms a large Lamina Groove
Articular Pillars- the superior and inferior articular processes are fused to form a pillar
Transverse Processes- consist of two parts that are separated by a deep sulcus or canal which provides a passage for the corresponding spinal nerve:
Anterior part - arises from the side of the body and finishes at the Anterior Tubercle
Posterior part - the ‘true’ transverse process, ends at the Posterior Tubercle
Transverse Foramen- passage for neurovascular structures, primarily the Vertebral Artery and its accompanying veins and sympathetic nerves
With the several bony protuberances and landmarks, C5 serves as the attachment site for many soft-tissues (SOURCE-3+6):
Muscle :
Deep Stabilisers - short muscles associated with the Spinous Process and Transverse Process (SOURCE-6):
Multifidus - insert onto the lateral aspects and tips of Spinous Process
Rotatores - Transverse Process to Spinous Process of higher segment
Interspinalis Cervicis - course between each segments Spinous Process
Longissimus Capitis - arises from Transverse Process
Iliocostalis Cervicis - attaches to Transverse Process
Longissimus Cevicis - inserts onto Transverse Process
Semispinalis Cervicis - insert onto the Spinous Process
Prevertebral Group
Longus Colli - Superior and Intermediate part arise from Transverse Process and Anterior Bodies, respectively. Inferior part inserts ontoAnterior Tubercleof Transverse Process
Lateral/ Superficial Muscles
Scalenes (all three)
Anterior Scalene - arises fromAnterior Tubercleof Transverse Process
Middle Scalene - arises from thePosterior Tubercleof Transverse Process
Posterior Scalene - arises fromPosterior Tubercleof Transverse Process
Levator Scapulae - (a variable attachment of unknown incidence)
Trapezius - inserts onto the Spinous Process via the Nuchal Ligament
Intervertebral Discs (above and below)
Ligament s
Region
Superficial Back Arm Line - through Trapezius
Deep Front Line - multiple direct attachments
Lateral Line - direct attachement through Sternocleidomastoid / Forward Head Posture
Superficial Back Line - through Erector Spinae
Unlike the rest of the Vertebral Column , Nerve Roots of the Cervical Spine exit superior of their corresponding vertebrae. The C5 Nerve Root traverses the inferior surface of C4 and superior surface of C5. At the base of the Brachial Plexus , the nerve root typically courses along with a motor branch to the Rhomboids and pierces the Middle Scalene . There is known variation in the course and formation of these peripheral nerves.
Direct Nerve Root branches:
Longus Capitis - ( C1 - Atlas , C2 - Axis , C3 and sometimes C4 and C5)
Peripheral Nerve - the C5 Nerve Root lends fibres to the following nerves:
Phrenic Nerve - ( C3 , C4 , C5)
Brachial Plexus - (C5, C6 , C7 , C8 , T1 )
Dorsal Scapular Nerve - (C5)
Long Thoracic Nerve - (C5, C6 and C7 )
Suprascapular Nerve - (C5 and C6 )
Lateral Pectoral Nerve - (C5, C6 and C7 )
Medial Pectoral Nerve - (C5, C6 and C7 )
Median Nerve (lateral root) - (C5, C6 and C7 )
Axillary Nerve - (C5 and C6 )
The following structures are innervated by the C5 Nerve Root (SOURCE-3)Motor
Diaphragm - ( Phrenic Nerve )
Prevertebral Muscle s
Longus Capitis - ( C1 - Atlas , C2 - Axis , C3 and sometimes C4 and C5)
Longus Colli - (ventral rami of C2 - Axis , C3 , C4 , C5 and C6 )
Middle Scalene - (ventral rami of C3 - C8 ) with the most superior attachment of the Scalenes , the Middle Scalene is often the only one to receive innervation this high (SOURCE-7)
Deltoid - ( Axillary Nerve )
Teres Minor - ( Axillary Nerve )
Sensory:
Dermatomes - C5 provides cutaneous sensory innervation over the lateral arm from Deltoid to base of the Thumb (SOURCE-8)
Radiculopathy - a C5 and C6 radiculopathy could refer Pain to the Suprascapular region (SOURCE-1)
Several C5 variations have been observed, including (SOURCE-1+11):
No penetration of Middle Scalene ~35% of cases
Penetration along with C6 ~24% of cases
C5 courses anterior of the Anterior Scalene in ~3% of cases, leaving it vulnerable to injury
While C5 is subject to many of the traumatic and degenerative pathologies that affect the Vertebral Column and their associated soft-tissues, the following discusses pathologies that are region specific. Akin to stepping on a running gardenhose, misalignment of C5 affects the exiting Nerve Root , known as a Radiculopathy , which may compromise the sensory or motor functions of the tissues it innervates. Additionally, misalignment of C5 may lead to approximation of its Zygapophyseal Joints and consequent referral to the skin over the Upper Trapezius , extending towards the Acromion and over the Spine of Scapula (SOURCE-8+13).
A pathology rather specific to C5 is Entrapment by the Scalenes . The Dorsal Scapular Nerve , which often arises exclusively from C5, is most commonly entrapped by a hypertrophied Middle Scalene (SOURCE-12). As the Peripheral Nerve does not contain sensory fibres, symptoms typically relate to Rhomboids or Levator Scapulae dysfunction (SOURCE-12). A distinct, albeit similar, compression injury may affect the C5 Nerve Root on a rare variable course anterior of the Anterior Scalene (SOURCE-11). In this region there is a notable reduction in overlying tissue, leaving the Nerve Root particularly vulnerable to injury to the extent that the compression of a backpack strap may be sufficiently noxious (SOURCE-11).
Affording their name to the sensation of Pain ,BurnersorStingersare a transient neuropathy usually associated with tramatic compression or traction of the C5 and C6 Nerve Root or its contribution to the Brachial Plexus (SOURCE-14+15). The mechanism often results from contact sports where there is a forced increase in distance between the Acromion and the Mastoid Process (SOURCE-14). Traction occurs when The Shoulder Girdle is forcefully depressed while the neck is forced away (contralateral Cervical - Lateral Flexion ) (SOURCE-14). Conversely, forceful Cervical - Lateral Flexion to the ipsilateral (same) side may compress the exiting nerve root (SOURCE-14). Additionally, a direct blow to the Supraclavicular Area may irritate these same nerves (SOURCE-15). The burning or stinging Pain that radiates down the upper limb is fleeting in nature, usually resolving within a few seconds to minutes, with persistent neurological symptoms indicative of severity (SOURCE-14). C5 is left particularly vulnerable to this type of injury as it experiences some of the greatest narrowing of the neuroforamen during Cervical - Lateral Flexion , Cervical - Rotation and Cervical - Extension (SOURCE-15). Conditions that narrow the neuroforamen are associated with the recurrence of Burners or Stingers (SOURCE-15).
Parsonage-Turner Syndrome (PTS) - also known asIdiopathic Brachial PlexopathyorNeuralgic Amyotrophy, is an acute, inflammatory or autoimmune neuropathy with an abrupt onset (SOURCE-16). Clinically this manifests as the acute, often inexplicable, onset of severe Pain in The Shoulder Girdle and weakness of more than one of its Muscles (SOURCE-16+17). Non-idiopathic PTS is most frequently the result of systemic or localised infectious or immunologic disorders, with less than half attributed to antecedent events such as viral infection or vaccinations (SOURCE-17). PTS typically affects the Superior Trunk of the Brachial Plexus (from C5 and C6 Nerve Root s) (SOURCE-16). The Suprascapular Nerve is most often (~97%) compromised with PTS, occuring concomitantly with involvement of other nerves in more than half of cases (SOURCE-17).
Although rare, a Neuropathy of particular concern is Diaphragm atic paralysis that may result from palsy of the Phrenic Nerve which arises from ventral rami of C3 , C4 and C5 (SOURCE-9). As C4 is the predominant contributor of nerve fibres, it is most common segement implicated in this injury, usually in the form of a Radiculopathy (SOURCE-9+10). Chronic disturbance to the Phrenic Nerve can lead to both trophic and nutritional disturbance which causes weakening and dysfunction of the Diaphragm (SOURCE-10).
A C5 Radiculopathy shares similarity to the following conditions (SOURCE-2):
Rotator Cuff Tear - differentiated by weakness in other muscles innervated by C5, including: Pectoralis Major , Biceps Brachii , Brachioradialis , Supinator
Suprascapular Nerve Entrapment - differentiated by weakness in other muscles innervated by C5, including: Pectoralis Major , Biceps Brachii , Brachioradialis , Supinator
Thoracic Outlet Syndrome - Pain or other symptoms often more diffuse and more consistent with Peripheral Nerves of the upper limb
Disc Herniation - a common cause of radiculopathy, often requiring an MRI to differentiate
The following observations may be related to C5 pathology/ dysfunction:
Cervical Spine - C5 is particularly vulnerable to narrowing of the intervertebral foramen during movements such as Cervical - Lateral Flexion , Cervical - Rotation and Cervical - Extension or postures such as Forward Head Posture (SOURCE-15). These movements may reproduce patients nerve-related Pain , which often radiates down the arm (SOURCE-15)
Muscle Weakness - any of the muscles innervated by C5 may display weakness or atrophy. GH Joint - Abduction and GH Joint - External Rotation likely affected
Scapular Dyskinesis - dysfunction of muscles such as the Deltoid and Rhomboids may cause abnormal Scapula mechanics at rest or through movement (SOURCE-12)
The following details the Range of Motion assessment specific to C5. For a more broad look at the Cervical Spine - see Cervical - Active Range of Motion . Landmarks on the C5 vertebrae may be tender, malaligned or restricted:
Passive Accessory Intervertebral Movements
Passive Physiological Intervertebral Movements
C2-7 Rotation - contralateral Cervical - Rotation could be provocative with the variable course of C5 anterior to the Anterior Scalene (SOURCE-11)
While a C5 Radiculopathy may impact Glenohumeral Joint and Scapulothoracic Joint motion in many directions, the most notable is (SOURCE-3+15):Ranges that may be affected (weak or Pain ful) by a C5 Radiculopathy in rough descending order (SOURCE-3+15):
The Nerve Root may be evaluated by virtue of the perfomance of the Muscles that share its innervation, known as Myotomes . For C5 active GH Joint - Abduction or Elbow - Flexion if performed against the resistance of the practitioner.
The Nerve Root may also be evaluated through its sensory distribution, known as a Dermatomes . For C5, refers to the skin over the Deltoid and a thin portion of the lateral forearm, terminating at the base of the Thumb (SOURCE-8).
Reflex testing can be performed for C5 using the Biceps Reflex Test .
The following Special Tests may be relevant where C5 pathology is suspected:
Spurling’s Test - for investigating Radiculopathy or compression of Zygapophyseal Joints , reproduces patients Pain (SOURCE-15)
Cervical Distraction Test - alleviation of patients referred Pain suggests Radiculopathy or compression of Zygapophyseal Joints
Cervical Quadrant - approximates Zygapophyseal Joints
For treating symptoms of Pain or restriction in any of the soft-tissues innervated by C5, see the treatment section of their respective pages. The following techniques may be used to improve the Mobility and relative position of C5 with the hopes of reducing radicular symptoms.
Stretching techniques used to improve the relative position of C5 generally aim to restore length in the superficial Cervical - Flexion Muscles to reduce the extent of Forward Head Posture (SOURCE-5). Additionally, restoring length to related fascial continuities has the capacity to improve C4 posture and movement.
Door Frame Neck Stretch - self-guided neck stretch with several variations
Seated Thoracic Rotation with Breathing - if associated with Thoracic - Rotation restriction
Swimmers Oblique Extensions - exercise that may be used to lengthen entire Lateral Line through large body-wide lateral-flexion range
Bent Over Lat Stretch - accessible active stretch with large GH Joint - Flexion or Horizontal GH Joint - Adduction range
Jefferson Curl - maximal stretch for posterior chain with emphasis on intersegmental movment of the Vertebral Column and capacity to add load
The following details Fascia l structures that may be implicated in C5 malalignment and a brief plausible mechanism: Fascial Lines
Deep Front Line - direct attachment to the transverse process through Longus Colli and Scalenes
Superficial Front Line - shortened Sternocleidomastoid perperuates Forward Head Posture
Superficial Back Line - restriction can produce hyperextension of the upper Cervical Spine
Superficial Back Arm Line - direct attachment through Trapezius
Initial Phase - early phase strength development should focus on quality of movement under no-to-low load and the promotion of neuromuscular coordination through isometric (or other) Muscle Contraction s. For C5, a likely area of focus is the Deep Neck Flexors ( Longus Colli , Longus Capitis , Rectus Capitis Anterior , Rectus Capitis Lateralis ) whose tone and strength should be increased relative to the superfical neck flexion muscles ( Sternocleidomastoid , Scalenes ) (SOURCE-5):
Deep Neck Flexor Endurance Test - performed as an exercise
Cervical Rotation Exercises - particularly valid for unilateral or rotational malalignment
Thoracic Extension Exercises - if Kyphosis of the Thoracic Spine is present
Quadruped Thoracic Rotation - if associated with Thoracic - Rotation restriction
Prone Cobra - isometric exercise that emphasises Middle and Lower Trapezius
Mid-Phase:
Scapula Control
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
Thoracic - Rotation - improvements in strength and range of motion could reduce the need for overcompensation from the neck:
Late Phase:
Reflexive Deep Neck Flexor Exercise - a dynamic deep neck flexor exercise
Glute Bridge - Neck Bridge variant
The following Mobilisation techniques may be indicated to correct malalignment of the C5 vertebrae or treat C5 Nerve Root pathology:
Joint Play - passive accessory movements performed without active movement Passive Accessory Intervertebral Movements
Cervical - PAVIMs - mid-cervical techniques
Passive Physiological Intervertebral Movements - assess C5 through more global, cervical-wide movements. May provide insight into which physiological movements are most affected.
Mobilisation with Movement - mobilisations applied with active movement
Dry Needling may be indicated for any hypertonic tissues ( Muscle or Fascia ) that directly or indirectly attach to C5, particularly if tight nodules or “trigger points” are identified. The following lists muscles with a dry needling procedure detailed on their page:
Upper Trapezius
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