Muscle:Iliocostalis Cervicis

Iliocostalis cervicis (also known as cervicalis ascendens) is the cervical continuation of the iliocostalis column — the most laterally placed of the erector spinae (superficial paraspinal) group. It bridges the thoracic rib cage to the lower cervical spine, making it a key postural muscle at the cervicothoracic junction. Its TrPs refer pain upward into the posterior neck and occipital region, and downward toward the interscapular area. Because of its position at the cervicothoracic junction, TrPs in this muscle are closely associated with the iliocostalis thoracis below and with cervical paraspinal muscles above, and satellite TrPs from a key TrP in the latissimus dorsi may activate the entire iliocostalis column including the cervicis.

Anatomy

The iliocostalis cervicis arises from the angles of ribs 3–6 (superior aspect) and inserts above into the posterior tubercles of the transverse processes of cervical vertebrae C4–C6. It lies lateral to the longissimus cervicis throughout.

The iliocostalis cervicis is the cranial continuation of the iliocostalis thoracis, which itself connects above to the transverse process of the seventh cervical vertebra. The two muscles are thus overlapping segments of the same lateral iliocostalis column, spanning continuously from the sacrum to the mid-cervical spine. Fig. 48.3 of Travell and Simons (Volume 2) illustrates this continuous column clearly.

The paraspinal musculature as a whole is simplified by thinking of it as two layers: a superficial layer of long-fibred longitudinal extensors (erector spinae), and a deep layer of shorter, more diagonal extensor rotators (transversospinal muscles). The iliocostalis cervicis is a member of the superficial layer.

Primary function: Acting bilaterally, extends the cervical and upper thoracic spine and maintains erect posture at the cervicothoracic junction. Acting unilaterally, produces ipsilateral lateral flexion and same-side rotation of the lower cervical vertebrae. Stabilises the vertebral column during flexion in the upper portion of the torso, acting in contrast to the anterior cervical and abdominal muscles and in opposition to gravity.

Innervation: Dorsal rami of the upper thoracic and lower cervical spinal nerves (approximately C6–T6). The lateral branches of the dorsal primary divisions innervate the longer, more superficial muscles.

Blood supply: Muscular branches of the occipital artery (from the external carotid artery) and dorsal branches of the posterior intercostal arteries.

Referred Pain Patterns

TrPs in the iliocostalis cervicis refer pain in a pattern consistent with its position at the cervicothoracic junction:

• Upward into the posterior neck and suboccipital region
• Downward into the interscapular region and upper thoracic back
• Lateral referral to the posterior shoulder girdle region

These patterns overlap with those of the iliocostalis thoracis (which refers pain to the chest wall and shoulder at midthoracic levels) and with cervical paraspinal muscles above (which refer pain to the head and neck). Determining which specific segmental level harbours the active TrP is important, as the depth and muscular length of a deeper-layer TrP can be difficult to distinguish.

The patient typically draws an up-and-down pattern to represent the pain referred from iliocostalis TrPs — in contrast to the crosswise pattern used to demonstrate pain from TrPs in the lower rectus abdominis. This up-and-down quality applies throughout the iliocostalis column, including the cervicis.

Activation and Perpetuating Factors

• Sudden overload: A quick awkward movement combining flexion and rotation of the neck and upper thorax, especially when the muscles are fatigued or chilled; disproportionate loading of one group of muscle fibres as the result of poor coordination
• Sustained overload: Sustained forward head posture; prolonged sitting with the neck flexed and rotated (e.g. cradling a telephone between ear and shoulder; sustained asymmetric computer workstation posture); working with the arms raised or forward for extended periods
• Repetitive microtrauma: Sustained or repeated muscular contraction over a period of time
• Whiplash: The whiplash type of accident causing sudden acceleration or deceleration rapidly stretches protectively stiffened spinal muscles and is likely to activate TrPs in the iliocostalis cervicis as part of the overall cervicothoracic paraspinal response
• Structural asymmetries: Lower limb-length inequality and small hemipelvis tilt the pelvis, producing a compensatory scoliosis that increases muscular load throughout the paraspinal column including the cervicis; forward head posture increases the load on the cervicothoracic junction muscles specifically
• Satellite TrP relationship: The iliocostalis cervicis may harbour a TrP that is a satellite induced by a key TrP in the latissimus dorsi or in the iliocostalis thoracis — the key TrP must be treated first for full recovery. An iliocostalis thoracis TrP that is itself a satellite of a latissimus dorsi key TrP can propagate satellite activity upward into the cervicis

Clinical Examination

Superficial Paraspinal Examination

Palpation of superficial paraspinals is less effective with the patient standing because of postural muscle tension and protective splinting by normal muscles. The examiner must obtain relaxation of the patient's back and neck muscles so that abnormally taut muscle fibres are distinguishable from adjacent normal, slackened fibres.

Seated position: When the seated patient leans forward, lets the head and neck relax, and dangles the arms between the legs, an involved iliocostalis cervicis may be detected as a taut rope-like band in the cervicothoracic paraspinal gutter, lateral to the longissimus.

Sidelying position (optimal): The patient lies on the uninvolved side with a pillow under the side of the abdomen for semiprone support. The degree of stretch is regulated by bringing the patient's knees toward the chest just far enough to take up the slack in the long erector spinae. The neck may require additional positioning to optimise stretch and relaxation of the cervicothoracic muscles. Flat palpation then elicits spot tenderness of a palpable nodule in a taut band, and often elicits patient-recognised referred pain.

Skin changes: The skin overlying involved paraspinal muscles may exhibit superficial tenderness and resistance to skin rolling (panniculosis) or trophedema. Identification and treatment of both panniculosis and the underlying TrPs may be critical to prompt recovery, particularly in the low thoracic and lumbar regions where panniculosis is most marked.

General Signs

Local areas of reduced skin resistance to direct current are characteristic of the musculoskeletal and myofascial symptoms of backache and neck pain with limitation of spinal motion.

Tightness of the more superficial group of muscles including the iliocostalis cervicis can be felt best when the patient is positioned between side-lying and prone. Patient examination reveals restricted range of back and neck motion, especially in flexion or rotation.

Differential Diagnosis

Condition	Distinguishing features
Cervicogenic headache	Iliocostalis cervicis TrPs referring upward to the posterior neck and occiput contribute to cervicogenic headache; distinguished from primary headache by TrP palpation reproducing the headache and by response to TrP inactivation; other cervical paraspinal muscles (semispinalis cervicis, multifidus, suboccipitals) are more commonly the primary source
Interscapular pain / thoracic outlet	TrPs in the iliocostalis cervicis referring downward into the interscapular region overlap with patterns from the rhomboids, middle trapezius, and iliocostalis thoracis; distinguished by systematic segmental TrP palpation and response to treatment
Cervical radiculopathy	Cervical radiculopathy causes pain radiating into the upper extremity with neurological signs; paraspinal TrPs alone do not produce neurological deficits — however, radiculopathy can activate paraspinal TrPs that persist after the nerve root compression has been relieved, producing stiffness and pain similar to the original radicular pain
Articular dysfunction	Segmental articular dysfunction at the cervicothoracic junction is commonly associated with iliocostalis cervicis TrPs; TrPs in the most superficial and longest muscles are associated with group (multi-level) dysfunctions; treating one often helps the other
Fibromyalgia	Any patient with chronic neck and back pain and additional widespread pain should be examined for fibromyalgia; fibromyalgia and TrPs are different diseases requiring different treatments; more than half of fibromyalgia patients also have TrPs
Latissimus dorsi TrP referral	The latissimus dorsi refers pain to the mid-back and posterior shoulder — it is the primary key TrP that activates the iliocostalis column as satellites; latissimus dorsi TrPs must be inactivated first

Treatment

Trigger Point Release — Spray and Stretch

Treatment of the iliocostalis cervicis follows the same principles as the iliocostalis thoracis. The less strenuous seated position chiefly stretches the long thoracic paraspinal muscles and is the starting point; the more strenuous long-sitting position provides greater stretch of the thoracic and upper lumbar paraspinal muscles, which unloads tension in the iliocostalis column including the cervicis.

Less strenuous seated position:

1. Patient sits in a chair with feet placed comfortably on the floor and legs apart
2. Patient leans forward, lets the head hang forward, and lets the arms drop between the knees
3. After a few initial sweeps of vapocoolant spray, the operator gradually increases pressure on the upper back to guide the patient's movement as the vapocoolant spray is directed over the paraspinal muscles bilaterally in long downward parallel sweeps
4. At the same time, to hyperflex the thoracic spine, the patient is told to take a deep breath, to exhale fully, and to curl or "Hump the back!" (the wrong instruction, "Arch your back!", causes the patient to extend rather than flex the spine)
5. Vapocooling is followed promptly by application of moist heat to rewarm the skin, then by active range of motion

For greater stretch at the cervicothoracic junction specifically, additional cervical flexion and contralateral rotation can be incorporated after the thoracic flexion is established.

PIR (postisometric relaxation): In the supine position, with the hips and knees flexed and held by the hands, the patient can augment the low back and thoracic stretch using PIR. The patient presses the buttocks downward against the bed (contracting the lumbar extensors) and then relaxes, pulling the thighs up toward the chest. For the cervicothoracic component, PIR of the ipsilateral neck flexors and contralateral rotators can be added.

Trigger Point Pressure Release

The patient can apply self-release therapy to TrPs in the superficial back muscles by lying supine on a tennis ball, either on the floor or on a bed with a large thin book placed under the ball. The patient moves around until the ball presses directly on the sensitive TrP in the upper thoracic paraspinal gutter; controlled body weight is used to apply gradually increasing pressure for a minute or more, until the spot loses its deep tenderness. Moist heat applied afterward and full range of motion enhance the beneficial effects.

Trigger Point Injection

The longissimus and iliocostalis TrPs at thoracic levels are clearly palpable and readily located for injection in all but very obese patients. At the upper thoracic and cervicothoracic level, injection requires care:

• When injecting the iliocostalis thoracis and cervicis in the upper thoracic region: the needle must be directed tangent to, and not between, the ribs to avoid pneumothorax
• Needle penetration of TrPs located more medially in the longissimus column refers pain caudally; a TrP located 1–2 cm more laterally in the iliocostalis column refers pain upward toward the shoulder and neck — this difference in referral direction helps confirm the correct muscle

The TrP injection is followed at once by a repetition of stretch and spray, then by moist heat and active range of motion.

Corrective Actions

Trigger Point Pressure Release (Self-Treatment)

Self-application of TrP pressure release using a tennis ball (see Treatment above).

Correction of Structural Inadequacies

A functional scoliosis develops to compensate for lateral tilting of the pelvis caused by a short leg when standing, or by a small hemipelvis when sitting. Such body asymmetry imposes persistent muscle strain throughout the paraspinal column including the iliocostalis cervicis, and must be corrected.

• Limb-length inequality: A difference of as little as 0.3 cm (1/8 in) in a short person should be corrected. The correction must be worn whenever the patient is on their feet, including bedroom slippers
• Asymmetrical pelvis (small hemipelvis): Pelvic tilt is corrected by placing enough pages or sheets of paper under the ischial tuberosity on the shorter side to level the pelvis exactly when sitting on a flat hard surface
• Forward head posture: A primary perpetuating factor for cervicothoracic paraspinal TrPs; correction of workstation ergonomics (monitor height, keyboard position, chair backrest) is essential

Modification of Activities

• Avoid cradling a telephone between the ear and shoulder — use a headset or speakerphone
• The workstation should allow the monitor to be at eye level so the head need not be held in sustained flexion or rotation
• The backrest of a chair should provide enough lumbar support to maintain the normal lumbar lordotic curve — this reduces forward head drift by restoring the normal lumbar-to-cervical postural chain
• Pick up any low object by bending the knees while keeping the back upright — transferring the load from the back muscles to the hip and knee extensors
• A particularly hazardous movement is a twisting turn while lifting or pulling; it is MUCH safer to rotate the body and face the load squarely

Modification of Environment

• The backrest of a chair should provide enough lumbar support to maintain the normal lumbar lordotic curve when the muscles relax
• A bed that is too soft and sags in the middle aggravates tension in the back and neck muscles — remedied by placing a plywood board between the mattress and the bed spring
• When sleeping on the side rather than supine, a pillow placed under the uppermost knee prevents the rotary torsion of the lumbar spine that occurs when the knee drops forward; the cervical pillow should maintain the head and neck in neutral alignment

Exercises

• In-bathtub Stretch Exercise: Performed in comfortably warm water; the patient actively leans forward with the knees straight and assists dorsal relaxation by letting the head hang forward, then walks the fingers down the shins until a pull is felt on the stretched paraspinal muscles, then a little further to slight discomfort. After holding for several seconds, tautness usually slackens; the patient leans back, relaxes, breathes deeply with abdominal respiration, then leans forward to take another step of the fingers to "take up the slack"
• Low-back Stretching Exercise: Supine; draw one knee to the chest with hands clasped around the thigh behind the knee (not the knee itself, to avoid forced knee flexion). Return that lower limb to the straight-leg starting position, then flex the other thigh to the chest. Finally, both legs are pulled to the chest
• Abdominal strengthening: Strong abdominal muscles provide 30–50% additional weight-carrying support to the thoracolumbar spine, reducing load on the paraspinal column; abdominal strengthening using Sit-back, Abdominal-curl, and Sit-up exercises should be performed slowly, not rapidly

Satellite Trigger Points

• Iliocostalis thoracis — caudal continuation; the two muscles function as a continuous column and frequently develop TrPs together
• Longissimus cervicis — medial partner at the same segmental level; commonly co-active
• Latissimus dorsi — key TrP that commonly activates the iliocostalis column as satellites; the latissimus must be treated first for full recovery
• Semispinalis cervicis — deep group at the same level; commonly co-active
• Multifidus (cervical) — deep group; commonly co-active
• Trapezius (upper) — key TrP frequently activating cervical paraspinal muscles as satellites

Related Pages

• Muscle:Iliocostalis Thoracis — caudal continuation; same column
• Muscle:Iliocostalis Lumborum — most caudal segment of the iliocostalis column
• Muscle:Longissimus Thoracis — medial partner; same superficial paraspinal group
• Muscle:Latissimus Dorsi — key TrP activating the iliocostalis column as satellites
• Muscle:Semispinalis Cervicis — deep group at cervicothoracic junction
• Muscle:Multifidus — deep group; fine vertebral stabilisation
• Pain:Low Back — diagnostic algorithm for paraspinal pain
• Pain:Neck and Interscapular — diagnostic algorithm including cervicothoracic paraspinal TrPs

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 9.
• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2: The Lower Extremities. Baltimore: Williams & Wilkins; 1992. Chapter 48 (anatomy and column relationships).