The spinous processes of C3-C6 are typically bifid (split into two tubercles at their tips), providing dual attachment points for the ligamentum nuchae, cervical interspinous ligaments, and deep cervical musculature. The bifid tip increases the surface area for ligament attachment and provides a wider base for the nuchal ligament.
The bifid nature of C3-C6 spinous processes must be recognised during posterior cervical surgery to avoid inadvertent dural exposure when drilling. The bifid spinous process is a landmark for midline identification. An absent or fused bifid tip at C5-C6 may indicate prior posterior surgery or congenital fusion. Tenderness over individual spinous processes localises facet joint or interspinous ligament pathology at that level.
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