Yatreyu: Created page with "'''Cervical multifidi''' are deep diagonal posterior cervical muscles whose trigger points (TrPs) refer pain strongly upward to the suboccipital region and downward over the neck and the upper part of the shoulder girdle. Unlike the longer semispinalis capitis, whose pain encircles the head to the temporal region, multifidi TrP pain is referred '''cephalad to the suboccipital region and caudad toward the scapula'''. Because TrPs in the cervical multifidi are closely ass..."

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Created page with "'''Cervical multifidi''' are deep diagonal posterior cervical muscles whose trigger points (TrPs) refer pain strongly upward to the suboccipital region and downward over the neck and the upper part of the shoulder girdle. Unlike the longer semispinalis capitis, whose pain encircles the head to the temporal region, multifidi TrP pain is referred '''cephalad to the suboccipital region and caudad toward the scapula'''. Because TrPs in the cervical multifidi are closely ass..."

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'''Cervical multifidi''' are deep diagonal posterior cervical muscles whose trigger points (TrPs) refer pain strongly upward to the suboccipital region and downward over the neck and the upper part of the shoulder girdle. Unlike the longer semispinalis capitis, whose pain encircles the head to the temporal region, multifidi TrP pain is referred '''cephalad to the suboccipital region and caudad toward the scapula'''.

Because TrPs in the cervical multifidi are closely associated with articular dysfunction at the same segmental levels, and because the articular dysfunction itself can activate and perpetuate the TrPs, satisfactory management of cervical musculoskeletal pain frequently requires evaluation and treatment of both the muscle TrPs and the associated cervical joint.

== Contents ==
* [[#Anatomy|1 Anatomy]]
* [[#Referred Pain Patterns|2 Referred Pain Patterns]]
* [[#Activation and Perpetuating Factors|3 Activation and Perpetuating Factors]]
* [[#Clinical Examination|4 Clinical Examination]]
* [[#Differential Diagnosis|5 Differential Diagnosis]]
* [[#Treatment|6 Treatment]]
** [[#Trigger Point Release|6.1 Trigger Point Release]]
** [[#Trigger Point Injection|6.2 Trigger Point Injection]]
** [[#Corrective Actions|6.3 Corrective Actions]]
* [[#Satellite Trigger Points|7 Satellite Trigger Points]]
* [[#Related Pages|8 Related Pages]]
* [[#References|9 References]]

== Anatomy ==

The cervical multifidi attach '''above''' to the spinous processes of vertebrae C₂ to C₅. They attach '''below''' to the articular processes of the last four cervical vertebrae (C₄ to C₇); multifidus fibres cross two to four vertebrae.

The cervical multifidi constitute the fourth and deepest layer of the posterior cervical muscles, together with the rotatores (Fig. 16.2). They are shorter and more angulated than the semispinalis cervicis and have digitations for every vertebral level from C₂ inferiorly. Since some digitations span more than one vertebra, TrPs in the multifidi could be found at any level between these processes, starting at about the interface between spinous processes C₃ and C₄, and continuing inferiorly as thoracic multifidi.

The anatomical designation of the multifidi into three names — semispinalis, multifidi, and rotatores — is quite arbitrary. In fact, there is a full and continuous transition of lengths at each spinal level. Each of these multiple digitations has its own endplate zone, so there are '''many''' endplate zones in the cervical paraspinal musculature on each side, and therefore many potential TrP locations.

'''Primary actions:''' Extension of the vertebral column when acting bilaterally; rotation of the vertebrae to the '''opposite''' side when acting unilaterally. The multifidi also contribute to lateral flexion of the spine. These deeper muscles seem to be designed for control and are said to control positional adjustments between vertebrae, rather than movements of the spine as a whole.

'''Innervation:''' Branches of the posterior primary divisions of the cervical spinal nerves.

'''Synergists''' (extension and rotation): Semispinalis cervicis; for each separate movement, additional synergists and antagonists are the same as those for the semispinalis cervicis.

== Referred Pain Patterns ==

A multifidus TrP in the cervical region refers pain and tenderness '''cephalad to the suboccipital region''' and '''caudad down the neck to the upper vertebral border of the scapula''' (Fig. 16.1D of the source volume).

The deeply placed cervical multifidi TrP location (Location 3 in Fig. 16.1A) and pain pattern are characteristic: the TrP is located approximately halfway between a spinous process and a lower transverse process.

The pain arising from the cervical multifidi is analogous to the pattern of pain arising from the corresponding deep layer of muscles found in the lumbar spine (see Chapter 48.2B of the source volume), in that both refer pain locally adjacent to the spinous process and may refer additional patterns several segments away from the TrP.

When cervical rotatores TrPs are present, they produce '''midline pain and tenderness at the segmental level of the TrP''', analogous to that described for thoracolumbar rotatores.

== Activation and Perpetuating Factors ==

* '''Articular dysfunction:''' The close association of TrPs with motor endplates, and the close association of TrPs with articular dysfunction, makes the complex and often enigmatic posterior cervical musculoskeletal pain symptoms easier to understand. Articular dysfunction itself can activate and perpetuate TrPs via increased nerve irritability from segmental dysfunction or entrapment
* Sustained forward head posture with the neck in flexion
* Motor vehicle accident (whiplash): the semispinalis cervicis, multifidi, and rotatores muscle groups can form articular dysfunctions at various levels of the cervical and upper thoracic spine depending on specific attachments
* Neuropathy: cervical radiculopathy from C₄–C₅ or C₅–C₆ can activate TrPs in the posterior cervical muscles; the radiculopathy and TrPs can occur separately or concurrently, and each must be diagnosed on its own criteria
* Facet joint articular dysfunction at the segmental levels spanned by the digitations

== Clinical Examination ==

Trigger points of the cervical multifidi can be located approximately halfway between a spinous process and a lower transverse process, exemplified at Location 3 in Figures 16.1A and D of the source volume.

Since there are digitations of the cervical multifidi for every segmental level from C₂ inferiorly, and since some digitations span more than one vertebra, TrPs in the multifidi could be found at any level between these processes.

The deepest muscles in the fourth layer — the rotatores — are often not as fully developed in the cervical region as they are in the thoracic region. These muscles lie too deep for the fibre direction of their taut bands to be identified by palpation. They must be identified by:
* Characteristic '''deep tenderness''' to pressure applied deep in the groove lateral to spinous processes
* '''Tenderness to applied pressure or tapping on the spinous process''' of the vertebra to which the muscle attaches — this tenderness testing is used also to identify dysfunctional spinal articulations

The segmental level of a TrP involvement can often be identified by a '''flattened spot''' in the normally smooth curvature of the thoracic region; when tested by forward flexion, at least one spinous process fails to stand out prominently as expected. Multiple bilateral deep short rotatores can look like the longer but less angulated multifidi; however, multifidi involvement would not cause as much restricted rotation as the rotatores do, and the multifidi are less likely to cause a contiguous series of pressure-sensitive vertebrae with restricted joint mobility.

'''Articular assessment:''' Altered segmental motion of the cervical spine to palpation is a common finding associated with posterior cervical muscular dysfunction. Restriction in '''all''' directions usually indicates a capsular (arthritic) pattern. TrPs in the neck muscles and cervical zygapophysial joints at corresponding levels can have remarkably similar pain patterns. The TrPs in the neck muscles and the cervical zygapophysial joints at corresponding levels are likely to be closely associated.

== Differential Diagnosis ==

{| class="wikitable"
|-
! Condition !! Distinguishing features
|-
| Cervical zygapophysial joint pain || Overlapping pain patterns of cervical zygapophysial joints and posterior cervical muscles are extensively documented; C₂–C₃ zygapophysial joints need particular consideration when dealing with semispinalis capitis and cervicis TrPs; C₃–C₄ and C₄–C₅ with multifidi TrPs; both must be treated — the myofascial and articular components are closely associated
|-
| Semispinalis cervicis TrPs || Semispinalis cervicis is superficial to the multifidi; both refer to the occipital and scapular regions; multifidi palpation is deeper and at a characteristic halfway-between-processes location; multifidi have more restricted rotation when involved; semispinalis cervicis TrPs are less likely to cause articular restriction
|-
| Cervical radiculopathy || Positive Spurling test; dermatomal limb signs or symptoms (radiculopathy from C₄–C₆ rarely fails to cause limb symptoms); electrodiagnostic findings; TrPs can coexist with radiculopathy — each diagnosed on its own criteria
|-
| Cervicogenic headache || Suboccipital articular dysfunction (OA, C₁, C₂) and TrPs commonly coexist; 91% of patients examined by Jaeger had at least 3 active TrPs; 10 of 11 patients had TrP palpation reproducing the headache; both conditions require treatment
|-
| Fibromyalgia || Widespread pain for at least 3 months; brief examination of designated fibromyalgia tender points allows clinical establishment or exclusion; fibromyalgia patients commonly also have myofascial TrPs contributing to their pain; TrP injections can produce dramatic results in fibromyalgia patients despite their intolerance of manual techniques
|}

== Treatment ==

=== Trigger Point Release ===

Treatment of full-range stretching is '''contraindicated''' across hypermobile joints. When TrPs cross hypermobile joints, use TrP pressure release, hold-relax (mild contraction), counterstrain, indirect myofascial release, or TrP injection.

Released as part of the diagonal posterior cervical muscle group, using the same technique as for the semispinalis cervicis (flexion-with-rotation spray and stretch, Fig. 16.7). See [[Muscle:Semispinalis_Cervicis#Trigger_Point_Release|Semispinalis Cervicis — Trigger Point Release]] for the full diagonal stretch technique.

Restriction may respond well to appropriate bilateral stretch and spray of the deep paraspinal muscles that span the level of the flattening, or to manual techniques designed to affect both joint and muscle function.

Injection of cervical multifidi TrPs bilaterally increased left lateral rotation 45° to reach full range of motion and increased right lateral rotation 25° to reach full range of motion in one patient with a chronically locked hypomobile cervical-occipital junction receiving osteopathic manipulation — demonstrating the power of deep paraspinal muscle shortening and the effectiveness of inactivating responsible TrPs.

=== Trigger Point Injection ===

TrPs in the multifidi are found at various levels about halfway between the spinous processes and the transverse processes of each vertebral segment spanned by digitations of the multifidi that harbour TrPs (Fig. 16.1A and D).

Reaching multifidi TrPs requires penetrating several layers of muscle — the semispinalis capitis and cervicis, after first passing through the trapezius and splenius capitis muscles. The TrP is usually encountered at least 2 cm (¾ in) deep to the skin, and may lie beyond the reach of a 3.8-cm (1½-in) needle — a '''5-cm (2-in) needle''' may be needed (Fig. 16.8). It helps to depress the skin on both sides of the needle while injecting.

The pain response to injection may seem out of proportion to the tenderness elicited by palpation, because of the depth of the TrPs.

Following injection, passive rotation stretch during vapocooling is performed; the patient then does active full rotations (two or three times in each direction), and moist heat is applied.

Vertebral artery avoidance: avoid injections deep into the lateral posterior neck at, or above, the level of the C₂ spinous process (Fig. 16.5).

=== Corrective Actions ===

Same as for [[Muscle:Semispinalis_Capitis#Corrective_Actions|Semispinalis Capitis — Corrective Actions]].

Additionally, where articular dysfunction is identified alongside TrP involvement, the extension dysfunctions of T₁ to T₄ should be treated using a manual stretch technique that incorporates contract-relax and forward flexion progressing down the spine segment by segment.

Patients who exhibit primary hypermobility require '''stabilising exercises rather than stretching exercises'''.

== Satellite Trigger Points ==

* [[Muscle:Semispinalis_Cervicis|Semispinalis cervicis]] — superficial to multifidi; co-active; similar pain distribution
* [[Muscle:Cervical_Rotatores|Cervical rotatores]] — deepest layer; immediately adjacent; co-active; produce midline spinous process pain
* [[Muscle:Semispinalis_Capitis|Semispinalis capitis]] — same posterior cervical complex
* [[Muscle:Splenius_Cervicis|Splenius cervicis]] — synergist for contralateral rotation
* [[Muscle:Trapezius/Upper|Upper trapezius]] — superficial layer; TrPs frequently co-active with posterior cervical complex

== Related Pages ==

* [[Pain:Occipital|Pain:Occipital]] — Suboccipital referral from cervical multifidi TrPs
* [[Pain:Head_and_Neck|Pain:Head and Neck]] — Diagnostic algorithm
* [[Muscle:Semispinalis_Cervicis|Muscle:Semispinalis Cervicis]] — Superficial companion muscle
* [[Muscle:Cervical_Rotatores|Muscle:Cervical Rotatores]] — Deepest layer, co-active

== References ==

* Travell JG, Simons DG. ''Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body''. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 16.

[[Category:Muscle]]
[[Category:Vol1 Ch16]]
[[Category:Head and Neck]]

Muscle:Cervical Multifidi - Revision history