OWinston Fong MD Scott C McGovern MD and Jeffrey C Wang MD

Dorn Spinal Therapy

Spine Healing Therapy

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1. How does the evaluation of a patient with a spine complaint begin?

A complete history and physical exam are performed. The purpose of the history and physical exam is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated.

2. What are some of the key elements to assess in the history of any spine problem?

• Chief complaint: Pain, numbness, weakness, gait difficulty, deformity

• Symptom onset: Acute vs. insidious

• Symptom duration: Acute vs. chronic

• Pain location: Is the pain primarily axial neck pain, arm pain, or a combination of both?

• Pain quality and character: Sharp vs. dull, radiating vs. stabbing vs. aching

• Temporal relationship of pain: Night pain, rest pain, or constant unremitting pain suggests systemic problems such as tumor or infection. Morning stiffness that improves throughout the day suggests an arthritic problem or an inflammatory arthropathy.

• Relation of symptoms to neck position: Increased arm pain with neck extension suggests nerve root impingement.

• Aggravating and alleviating factors: Is the pain mechanical (activity-related) or nonmechanical (not influenced by activity) in nature?

• Family history: Inquire about diseases such as ankylosing spondylitis or rheumatoid arthritis.

• Concurrent medical illness: Diabetes, peripheral neuropathy, peripheral vascular disease

• Systemic symptoms: A history of weight loss or fever suggests possibility of tumor or infection.

• Functional impairment: Loss of balance, gait or balance difficulty, loss of fine motor skills in the hands

• Prior treatment: Include both nonoperative and operative measures.

• Negative prognostic factors: Pending litigation, Workers' Compensation claim

3. What disorders should be considered in the differential diagnosis of neck/arm pain?

• Degenerative spinal disorders: discogenic pain, radiculopathy, myeloradiculopathy, myelopathy

• Soft tissue disorders: sprains, myofascial pain syndromes, fibromyalgia, whiplash syndrome

• Inflammatory disorders: rheumatoid arthritis, ankylosing spondylitis

• Infections: discitis, osteomyelitis

• Tumors: metastatic vs. primary tumors

• Intraspinal disorders: tumors, syrinx

• Systemic disorders with referred pain: angina, apical lung tumors (Pancoast tumor)

• Shoulder and elbow pathology: rotator cuff disorders, medial epicondylitis

Peripheral nerve entrapment syndromes: radial, ulnar or median nerve entrapment, suprascapular neuropathy

• Thoracic outlet syndrome

• Psychogenic pain

4. What are the basic elements of an examination of any spinal region?

• Inspection • Neurologic exam

• Palpation • Evaluation of related areas (e.g. shoulder joints)

5. What should the examiner look for during inspection of the cervical region?

During the initial encounter, much can be learned from observing the patient. Assessment of gait and posture of the head and neck is important. Patients should undress to allow inspection of anatomically related areas, including the shoulders, back muscles, and scapulae.

6. What is the purpose of palpation during assessment of the cervical region?

To examine for tenderness and locate bone and soft tissue pathology. Specific areas of palpation correspond to specific levels of the spine:

Thyroid cartilage C4-C5 • First cricoid ring C6

Spinous processes should be palpated and checked for alignment. If tenderness is detected, it should be noted whether the tenderness is focal or diffuse and the area of maximum tenderness should be localized.

7. In which three planes is ROM assessed for the cervical spine?

• Flexion/extension • Right/left rotation

• Right/left bending

8. What is normal range of motion of the cervical spine?

Clinical estimates of motion are more commonly used in office practice. Flexion may be reproducibly measured using the distance from the chin to the sternum. For extension, the distance from the occiput to the dorsal spine may be helpful. Distances can be described in terms of fingerbreadths or measured with a ruler. The normal patient, for example, can nearly touch chin to chest in flexion and bring the occiput to within three or four fingerbreadths of the posterior aspect of the cervical spine in extension. Normal rotation permits the chin to align with the shoulder.

9. Describe an overview of the approach to the neurologic exam for cervical disorders.

The goal of examination is to determine the presence or absence of a neurologic deficit. If present, the level of a neurologic deficit is determined through testing of sensory, motor, and reflex function. The neurologic deficit may arise from pathology at the level of the spinal cord, nerve root, brachial plexus, or peripheral nerve. Examination of the cervical region is focused on the C5 to T1 nerve roots because they are responsible for supplying the upper extremities. For each nerve root, the examiner tests sensation, strength, and, if one exists, the appropriate reflex. (Table 4-1).

Table 4-1.

Testing Sensory, Motor, and Reflex Function

LEVEL

SENSATION

MOTOR

REFLEX

C5

Lateral arm (axillary patch)

Deltoid

Biceps

CS

Lateral forearm

Wrist extension, biceps

Brachioradialis

C7

Middle finger

Triceps, wrist flexion, finger extension

Triceps

CS

Small finger

Finger flexion

None

T1

Medial arm

Interossei

None

10. How is sensation examined?

Sensation can be assessed using light touch, pin prick, vibration, position, temperature, and two-point discrimination. In assessing sensation, it is helpful to assess both sides of the body simultaneously. In this manner, sensation that is intact but subjectively decreased compared with the contralateral side can be easily documented.

11. What are the neural pathways tested during sensory examination?

• Spinothalamic tracts: transmit pain and temperature sensation

• Posterior columns: transmit two-point discrimination, position sense and vibratory sensation

12. How is motor strength graded? How are reflexes graded?

Table 4-2. Grading Motor Strength and Reflexes

MOTOR GRADE

FINDINGS

5

Full range of motion against full resistance

4

Full range of motion against reduced resistance

3

Full range of motion against gravity alone

2

Full range of motion with gravity eliminated

1

Evidence of contractility

0

No contractility

REFLEX GRADE

FINDINGS

4+

Hyperactive

3+

Brisk

2+

Normal

1+

Diminished

0

Absent

13. What is the significance of hyperreflexia? An absent reflex?

Hyperreflexia signifies an upper motor neuron lesion. An absent reflex implies pathology at the nerve root level(s) that transmits the reflex (in the lower motor neuron).

14. What is radiculopathy?

Radiculopathy is a lesion that causes irritation of a nerve root (lower motor neuron). It involves a specific spinal level with sparing of levels immediately above and below. The patient may report pain, a burning sensation, or numbness that radiates along the anatomic distribution of the affected nerve root. Other signs include severe atrophy of muscles and loss of the reflex supplied by the nerve. Severe radiculopathy may result in the flaccid paralysis of muscles supplied by the nerve.

15. What symptoms are associated with a C5-C6 disc herniation? Explain.

A disc herniation at the C5-C6 level causes compression of the C6 nerve root. Thus, weakness of biceps and wrist extensors, loss of the brachioradialis reflex, and diminished sensation of the radial forearm into the thumb and index finger are expected. As there are eight nerve roots and seven cervical vertebrae, the C1 nerve root exits above the C1 vertebra, the C2 nerve root below it, and so on. Thus, the C2 nerve root exits through its neuroforamen adjacent to the C1-C2 disc. The nerve root of the inferior vertebra of a given motion segment (e.g. C3 for C2-C3 disc, C7 for C6-C7 disc) is the one typically affected by a herniated disc.

16. Describe testing of the cervical nerve roots.

Table 4-3. Testing the Cervical Nerve Roots

ROOT

DISC LEVEL

SENSATION

REFLEX

MOTOR LEVEL

C3

C2-C3

Posterior neck to mastoid

None

Nonspecific

C4

C3-C4

Posterior neck to scapula ± anterior chest

None

Nonspecific

C5

C4-C5

Lateral arm (axillary patch) to elbow

± Biceps

Deltoid ± biceps

CS

C5-C6

Radial forearm to thumb

Biceps, brachioradialis

Biceps, wrist extensors

C7

C6-C7

Midradial forearm to middle finger ± index/ring fingers

Triceps

Triceps, wrist flexors, finger extensors

C8

C7-T1

Ulnar forearm to little and ring fingers

None

Finger flexors ± intrinsics

T1

T1-T2

Medial upper arm

None

Hand intrinsics

17. What provocative maneuvers are useful in examining a patient with a suspected radiculopathy? Explain how each is carried out.

Spurling's test (Fig. 4-1) is used to assess cervical nerve roots for stenosis as they exit the foramen. The patient's neck is extended and rotated toward the side of the pathology. Once the patient is in this position, a firm axial load is applied. If radicular symptoms are worsened by this maneuver, the test is said to be positive. It is thought that the extended and rotated position of the neck decreases the size of the foramen through which the nerve roots exit, thereby exacerbating symptoms when an axial load is applied.

• Axial cervical compression test: Arm pain that is elicited by axial compressive force on the skull and relieved by distractive force suggests that radicular symptoms are due to neuroforaminal narrowing

• Valsalva maneuver: This maneuver may increase radicular symptoms. Increased intraabdominal pressure simultaneously increases cerebrospinal pressure, which, in turn increases pressure about the cervical roots.

• Shoulder abduction test: Patients with cervical radiculopathy may obtain relief of radicular symptoms by holding the shoulder in an abducted position, which decreases tension in the nerve root (Fig. 4-2)

18. What is Adson's test?

Adson's test helps to distinguish thoracic outlet syndrome from cervical radiculopathy. The affected arm is abducted, extended, and externally rotated at the shoulder while the examiner palpates the radial pulse. The patient turns the head toward the affected side and takes a deep breath. In a positive Adson's test, the radial pulse on the affected side is diminished or lost during the maneuver. A positive test suggests thoracic outlet syndrome (compression of the subclavian artery by a cervical rib, scalenus anticus muscle, or other cause).

19. What is cervical myelopathy? How does it present?

Myelopathy is the manifestation of cervical spinal cord compression. Cervical myelopathy arising from spinal cord compression due to cervical degenerative changes is the most common cause of spinal cord dysfunction in patients

Figure 4-1. Spurling's test.

older than 55 years. Vague sensory and motor symptoms involving the upper and/or lower extremities are common. Lower motor neuron changes occur at the level of the lesion, with atrophy of upper extremity muscles, especially the intrinsic muscles of the hands. Upper motor neuron findings are noted below the level of the lesion and may involve both the upper and lower extremities. Lower extremity spasticity and hyperreflexia are common. There may be relative hyperreflexia in the legs compared with the arms. Hoffmann's sign and Babinski's sign may be present. Additional findings may include neck pain and stiffness, spastic gait, loss of manual dexterity, or problems with sphincter control.

20. What reflexes or signs should be assessed when evaluating a patient with suspected cervical myelopathy? How are they evaluated?

• Babinski's test is performed by stroking the lateral plantar surface of the foot from the heel to the ball of the foot and curving medially across the heads of the metatarsals. It is termed positive if there is dorsiflexion of the big toe and fanning of the other toes (Fig. 4-3)

• Hoffmann's sign is performed on the patient's pronated hand while the examiner grasps the patient's middle finger (Fig. 4-4). The distal phalanx is forcefully and quickly flexed (almost a flicking motion) while the examiner observes the other fingers and thumb. The test is termed positive if flexion is seen in the thumb and/or index finger. Hoffmann's sign implies an upper motor lesion in the cervical spinal region as it is an upper extremity reflex. In contrast, pathology anywhere along the entire spinal cord can lead to a positive Babinski sign.

Figure 4-3. Babinski's test.

Finger escape sign (finger adduction test) is performed by asking the patient to hold all digits of the hand in an extended and adducted position. With myelopathy, the two ulnar digits will fall into flexion and abduction usually within 30 seconds.

Inverted radial reflex is elicited by tapping the distal brachioradialis tendon. The reflex is present when the tapping produces spastic contraction of the finger flexors and suggests cord compression at the C5-C6 level. The scapulohumeral reflex is performed by tapping the tip of the spine of the scapula. If the scapula elevates or the humerus abducts, it is termed a hyperactive reflex suggesting upper motor neuron dysfunction above the C4 cord level.

Lhermitte's sign is a generalized electric shock sensation that involves the upper and lower extremities as well as the trunk and it is elicited by extreme flexion or extension of the head and neck. Clonus. Upward thrusting of the ankle joint leads to rhythmic, repetitive motion of the ankle joint due to reflex contraction of the gastrocnemius-soleus complex due to lack of central nervous system inhibition.

Key Points

1. A comprehensive patient history and physical examination is the first step in diagnosis of a spine complaint.

2. A major goal of the initial patient evaluation is to differentiate common nonemergent spinal conditions such as acute nonspecific neck pain and cervical spondylosis from serious disorders such as spinal infections, spinal tumors, or cervical myelopathy.

3. Nonspinal pathology may mimic the symptoms of spinal disorders and must be considered in the differential diagnosis.

Websites

1. Cervical spine exam for neck and shoulder conditions (video): http://www.hss.edu/conditions_13653.asp

2. Provocative tests in cervical spine examination: historical basis and scientific analyses: http://www.painphysicianjournal.com/2003/ april/2003;6;199-205.pdf

3. Demonstration of a patient with ankle clonus (video): http://en.wikipedia.org/wiki/Clonus

BiBLiOGRAPHY

1. Albert TJ: Physical Examination of the Spine. London, Thieme, 2004.

2. Hoppenfeld S: Physical Exam of the Spine and Extremities. 1st ed. New York: Appleton & Lange, 1976.

3. Macnab I, McCulloch J. Neck Ache and Shoulder Pain. 1st ed. Baltimore: Lippincott Williams & Wilkins; 1994.

4. Rainville J, Noto DJ, Jouve C, et al., Assessment of forearm pronation strength in C6 and C7 radiculopathies. Spine 2007; 32:72-75.

5. Scherping SC. History and Physical Examination. In: Frymoyer JW, Wiesel sW, editors. The Adult Spine: Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004, p. 49-68.

6. Standaert CJ, Herring SA, Sinclair JD. Patient history and physical examination—cervical, thoracic and lumbar. In: Herkowitz HN, Garfin SR, Eismont FJ, et al., Rothman-Simeone The Spine. 5th ed. Philadelphia: Saunders; 2006, p. 169-186.

7. Zeidman SM. Evaluation of patients with cervical spine lesions. In: Clark CR, editor. The Cervical Spine. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005, p. 149-165.

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