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

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1. What are the most common reasons for referral to evaluate the thoracic spinal region?

Pain and spinal deformity. The differential diagnosis of thoracic pain is extensive and includes both spinal and nonspinal etiologies. Spinal deformities (e.g., scoliosis, kyphosis) are generally painless in children but may become symptomatic in adult life.

2. What are some common spinal causes of thoracic pain?

• Degenerative disorders: spondylosis, spinal stenosis, disc herniation

• Fracture: traumatic, pathologic

• Metabolic: osteoporosis, osteomalacia

• Deformity: kyphosis, scoliosis, trauma

• Neurogenic: spinal cord neoplasm, arteriovenous malformation, inflammatory (e.g., herpes zoster)

3. What are some common nonspinal causes of thoracic pain?

• Intrathoracic

• Cardiovascular (angina, aortic aneurysm)

• Pulmonary (pneumonia, carcinoma)

• Mediastinal (mediastinal tumor)

• Intra-abdominal

• Hepatobiliary (hepatitis, cholecystitis)

• Gastrointestinal (peptic ulcer, pancreatitis)

• Retroperitoneal (pyelonephritis, aneurysm)

• Musculoskeletal

• Post-thoracotomy syndrome

• Polymyalgia rheumatica

• Fibromyalgia

• Rib fractures

• Intercostal neuralgia

4. What should an examiner assess during inspection of the thoracic spinal region?

The patient should be undressed, and posture should be evaluated in both frontal and sagittal planes. Shoulder or rib asymmetry suggests the presence of scoliosis. A forward-bending test should be performed to permit assessment of rib cage and paravertebral muscle symmetry. If increased thoracic kyphosis is noted, it should be determined whether the kyphotic deformity is flexible or rigid. Leg lengths should be assessed. Look for any differences in height of the iliac crests. Note any skin markings such as cafe-au-lait spots, hairy patches, or birthmarks that may suggest occult neurologic or bony pathology.

5. What is the usefulness of palpation during examination of the thoracic spine?

Palpation allows the examiner to locate specific areas of tenderness, which aids in localization of pathology. Tenderness over the paraspinal muscles should be differentiated from tenderness over the spinous processes.

6. How precisely is range of motion assessed in the thoracic region?

Range of motion is limited in the thoracic region, and precise assessment is not an emphasized component of the thoracic spine exam. Nevertheless, thoracic range of motion is tested in all planes. Flexion-extension is limited by facet joint orientation, rib cage stability, and small intervertebral disc size. Thoracic rotation is typically greater than lumbar rotation due to facet orientation. Testing of lateral bending is relevant in assessing the flexibility of thoracic scoliosis. Asymmetric range of motion, especially in forward-bending, suggests the presence of a lesion that irritates neural structures, such as a tumor or disc herniation.

7. How is the neurologic examination of the thoracic spinal region performed?

Sensory levels are assessed by testing for light touch and pin-prick sensation. The exiting spinal nerves create band-like dermatomes (T4, nipple line; T7, xiphoid process; T10, umbilicus; T12, inguinal crease) (Fig. 5-1). Motor function is assessed by having the patient perform a partial sit-up and checking for asymmetry in the segmentally innervated rectus abdominis muscle. Weakness causes the umbilicus to move in the opposite direction and is termed Beevor's sign. Reflex testing consists of evaluation of the superficial abdominal reflex.

8. What is the superficial abdominal reflex? What does it signify?

The superficial abdominal reflex is an upper motor neuron reflex. It is performed by stroking one of the four abdominal quadrants. The umbilicus should move toward the quadrant that was stroked. The reflex should be symmetric from side to side. Asymmetry suggests intraspinal pathology (upper motor neuron lesion) and is assessed with magnetic resonance imaging (MRI) of the spine.

9. What findings in the history and physical exam suggest the presence of a thoracic disc herniation?

Clinically significant thoracic disc herniation is rare. It is difficult to reach an accurate diagnosis from history and physical exam alone. Thoracic disc herniations may cause thoracic axial pain, thoracic radicular pain, myelopathy, or a combination of these symptoms. Neurologic findings may include nonspecific lower extremity weakness, ataxia, spasticity, numbness, hyperreflexia, clonus, and bowel or bladder dysfunction.

LUMBAR SPINE EXAM

10. What pathologies should be considered in the differential diagnosis of low back pain?

• Soft tissue disorders (sprains, myofascial pain syndromes, fibromyalgia)

• Degenerative spinal disorders (disc herniation, spinal stenosis, facet joint arthritis)

• Spinal instabilities (e.g. spondylolisthesis)

• Rheumatologic disorders (rheumatoid arthritis, Reiter's syndrome, psoriatic arthritis, ankylosing spondylitis)

• Infection (bacterial, tuberculosis, fungal, HIV)

• Tumor (primary spine tumors, metastatic tumors)

• Metabolic disorders (osteoporosis, osteomalacia, Paget's disease)

• Hematologic disorders (sickle-cell disease)

• Systemic disorders with referred pain (peptic ulcers, cholecystitis, pancreatitis, retrocecal appendicitis, dissecting abdominal aortic aneurysm, pelvic inflammatory disease, endometriosis, prostatitis)

• Psychogenic pain

11. Does the age of the patient with low back pain or lower extremity radicular symptoms suggest an etiology?

Yes. Although no diagnosis is unique to a single age group, some generalizations apply:

• Less than 10 years: consider spinal infection or tumor

• 10 to 25 years: disorders involving repetitive loading and trauma: spondylolysis, isthmic spondylolisthesis, Scheuermann's disease, fractures, apophyseal ring injury

• 25 to 55 years: annular tear, disc herniation, isthmic spondylolisthesis

• Over 60 years: spinal stenosis, degenerative spondylolisthesis, metastatic disease

12. What factors in the patient history should prompt the examiner to consider further diagnostic testing, such as laboratory tests or imaging studies, during evaluation of symptoms of acute low back pain?

Factors that may indicate serious underlying pathology are termed red flags and include fever, unexplained weight loss, bowel or bladder dysfunction, cancer history, significant trauma, osteoporosis, age older than 50 years, failure to improve with standard treatment, and a history of alcohol or drug abuse.

13. What is a simple method for differentiating spinal symptoms due to physical disease from symptoms due to inappropriate illness behavior before the patient is examined?

Important clinical information can be obtained by having the patient complete a pain diagram. Pain diagrams completed by patients with physical disease (e.g. disc herniation, spinal stenosis) tend to be localized, anatomic, and proportionate. Pain diagrams completed by patients with magnified or inappropriate illness behavior tend to be regional, nonanatomic, and highly exaggerated.

14. What are the basic elements of a physical examination directed at the lumbar spine?

Examination should address the lumbar region, pelvis, hip joints, lower limbs, gait, and peripheral vascular system. A complete exam should include:

1. Inspection

2. Palpation

3. Range of motion (lumbar spine, hips, knees)

4. Neurologic exam (sensation, muscle testing, reflexes)

5. Assessment of nerve root tension signs

6. Vascular exam

15. What is looked for during inspection?

During the initial encounter, much can be learned from observing the patient. Abnormalities of gait (e.g. a drop foot gait or Trendelenburg gait) and abnormal posturing of the trunk are important clues for the examiner. It is also helpful to watch patients undress to observe how freely and easily they are able to move the trunk and extremities. In addition, the base of the spine should be inspected for a hairy patch or any skin markings that may be associated occult intraspinal anomalies. Waistline symmetry should be noted as asymmetry suggests lumbar scoliosis. The overall alignment and balance of the spine should be assessed by dropping a plumb line from the C7 spinous process to see that it is centered on the sacrum. If it is not, the lateral distance from the gluteal cleft should be noted.

16. What is the purpose of palpation?

To examine for tenderness and localize pathology. Palpation must include the spinous processes as well as the adjacent soft tissues. The area of the sciatic notch should be deeply palpated to look for sciatic irritability. Specific areas of palpation correspond to specific levels of the spine (e.g. iliac crest, L4-L5; posterior superior iliac spine, S2).

17. How is range of motion assessed?

In the spine, motion is assessed in three planes: flexion/extension, right/left bending, and right/left rotation. Range of motion can be estimated in degrees or measured with an inclinometer. It is important to note that a significant portion of lumbar flexion is achieved through the hip joints. The normal range of motion for forward flexion is 40° to 60°; for extension, 20° to 35°; for lateral bending, 15° to 20°; and for rotation, 3° to 18°.

18. What is Schober's test?

Schober's test is a simple clinical test useful to evaluate spinal mobility. This test is based on the principle that the skin over the lumbar spine stretches as a person flexes forward to touch the toes. A tape measure is used to mark the skin at the midpoint between the posterior superior iliac crests and at points 10 cm proximal and 5 cm distal to this mark while the patient is standing. The patient is then asked to bend forward as far as possible, and the distance between the two marked points is measured with the patient in the flexed position. In 90% of asymptomatic persons, there is an increase in length of at least 5 cm. This maneuver eliminates hip flexion and is a true indication of lumbar spine movement.

19. How is the neurologic examination of the lumbar region performed?

Neurologic examination of the lumbar region focuses primarily on a sequential examination of nerve roots. For each nerve root, the examiner tests sensation, motor strength, and, if one exists, the appropriate reflex (see Table 5-1).

Table 5-1.

Neurologic Examination of the Lumbar Region

LEVEL

SENSATION

MOTOR

REFLEX

L1

Anterior thigh

Psoas (T12, L1, L2, L3)

None

L2

Anterior thigh, groin

Quadriceps (L2, L3, L4)

None

L3

Anterior and lateral thigh

Quadriceps (L2, L3, L4)

None

L4

Medial leg and foot

Tibialis anterior

Patellar

L5

Lateral leg and dorsal foot

Extensor hallucis longus

None

S1

Lateral and plantar foot

Gastrocnemius, peroneals

Achilles

S2—S4

Perianal

Bladder and foot intrinsics

None

20. What provocative maneuvers are used to assess a patient with a suspected lumbar radiculopathy?

The standard straight-leg raise test and its variants increase tension along the sciatic nerve and are used to assess the L5 and S1 nerve roots. The reverse straight leg raise test increases tension along the femoral nerve and is used to assess the L2, L3, and L4 nerve roots.

21. Describe how the straight leg raise test and the femoral nerve stretch test are performed.

The straight-leg raise test is a tension sign that may be performed with the patient supine (Lasegue's test; Fig. 5-2) or sitting (flip test; Fig. 5-3). The leg is elevated with the knee straight to increase tension along the sciatic nerve, specifically the L5 and S1 nerve roots. If the nerve root is compressed, nerve stretch provokes radicular pain. Back pain alone does not constitute a positive test. The most tension is placed on the L5 and S1 nerve roots during a supine straight-leg raise test between 35° and 70° of leg elevation. A variant of this test is the bowstring test, in which the knee is flexed during the standard supine straight-leg raise test to reduce leg pain secondary to sciatic nerve stretch. Finger pressure is then applied over the popliteal space at the terminal aspect of the sciatic nerve in an attempt to reestablish radicular symptoms.

The femoral nerve stretch test (or reverse straight-leg raise test) increases tension along the femoral nerve, specifically the L2, L3, and L4 nerve roots (Fig. 5-4). It may be performed with the patient in the prone position or in the lateral position with the affected side upward. The test is performed by extending the hip and flexing the knee. This is exactly opposite to the standard straight-leg raise test. The femoral nerve stretch test is considered positive if radicular pain in the anterior thigh region occurs.

22. What is the contralateral straight-leg raise test? Why is it a significant test?

This test is performed in the same fashion as the standard straight-leg raise test except that the asymptomatic leg is elevated. If this test reproduces the patient's sciatic symptoms in the opposite extremity, it is considered positive. A positive test is strongly suggestive of a disc herniation medial to the nerve root (in the axilla of the nerve root). The combination of a positive straight-leg raise test on the symptomatic side and a positive contralateral straight-leg raise test is the most specific clinical test for a disc herniation, with accuracy approaching 97%.

23. What nerve root is affected by a posterolateral disc herniation?

The nerve roots of the lumbar spine exit the spinal canal beneath the pedicle of the corresponding numbered vertebra and above the caudad intervertebral disc. The most common location for a lumbar disc herniation is posterolateral. This type of disc herniation compresses the traversing nerve root of the motion segment. For example, a posterolateral disc herniation at the L4-L5 level would compress the traversing nerve root (L5).

24. What nerve root is affected by a disc herniation lateral to or within the neural foramen?

A disc herniation lateral to or within the neural foramen compresses the exiting nerve root of the motion segment. For example, a disc herniation at the L4-L5 level located in the region of the neural foramen compresses the exiting L4 nerve root and spares the traversing L5 nerve root.

25. What nerve roots are affected by a central disc herniation?

A central disc herniation can compress one or more of the caudal nerve roots. A large central disc herniation is a common cause of a cauda equina syndrome.

26. What is cauda equina syndrome?

Cauda equina syndrome is a symptom complex that includes low back pain, unilateral or bilateral sciatica, lower extremity motor weakness, sensory abnormalities, bowel or bladder dysfunction, and saddle anesthesia. Cauda equina syndrome may result from acute or chronic compression of the nerve roots of the cauda equina. Causes of cauda equina syndrome include massive central lumbar disc protrusion, spinal stenosis, epidural hematoma, spinal tumor, and fracture. The syndrome can result in permanent motor deficit and bowel and bladder incontinence. Once identified, cauda equina syndrome constitutes a true surgical emergency because it can be irreversible if not treated promptly with surgical decompression.

27. What are Waddell's signs?

Waddell described five categories of tests that are useful in evaluating patients with low back pain. These signs do not prove malingering but are useful to highlight the contribution of psychologic and/or socioeconomic factors to spinal symptoms. Presence of three of more of the signs is considered significant. Isolated positive signs are not considered significant. Waddell's tests include:

1. Superficial tenderness: Nonorganic tenderness with light touch over a wide lumbar area or deeper tenderness in a nonanatomic distribution.

2. Simulation: Maneuvers that should not be uncomfortable are performed. If pain is reported, nonorganic pathology is suggested. Examples of such tests include production of low back pain with axial loading of the head or when the shoulders and pelvis are passively rotated in the same plane.

3. Distraction: The examiner performs a provocative test in the usual manner and rechecks the test when the patient is distracted. For example, a patient with a positive straight-leg raise test in the supine position can be assessed with a straight-leg raise test in the seated position under the guise of examining the foot or another part of the lower extremity. If the distraction test is negative but a formal straight-leg raise test in the supine position is positive, this finding is considered a positive sign.

4. Regionalization: Presence of findings that diverge from accepted neuroanatomy. For example, entire muscle groups, which do not have common innervation, may demonstrate giving way on strength testing or sensory abnormalities may not follow a dermatomal distribution.

5. Overreaction: Disproportionate response to examination may take many forms such a collapsing, inappropriate facial expression, excessive verbalization, or any other type of overreaction to any aspect of the exam.

28. During assessment of a lumbar spine problem, what two nonspinal pathologies should be ruled out during the physical exam?

Degenerative arthritis of the hip joint and vascular disease involving the lower extremities. The presentation of these pathologies and common spinal problems can overlap. Anterior thigh pain may be due to either nerve impingement involving the upper lumbar nerve roots (L2, L3, L4) or hip arthritis. Range-of-motion testing of the hip joints can rule out hip pathology. Lower extremity claudication may be due to either vascular disease or lumbar spinal stenosis (neurogenic claudication). Assessment of peripheral pulses is helpful in diagnosing these problems.

29. How is the sacroiliac joint assessed?

Sacroiliac pain is difficult to confirm on clinical assessment and generally requires a diagnostic joint injection under radiographic control for confirmation. Clinical tests that have been described to assess this joint include:

• Patrick's test: With the patient supine, the knee on the affected side is flexed and the foot placed on the opposite patella. The flexed knee is then pushed laterally to stress the sacroiliac joint. This is also called the FABER test (flexion-abduction-external rotation).

• Pelvic compression test: With the patient supine, the iliac crests are pushed toward the midline in an attempt to elicit pain in the sacroiliac joint.

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 non-emergent spinal conditions such as acute nonspecific thoracic or lumbar pain and degenerative spinal disorders from serious and urgent problems such as spinal infections, spinal tumors or cauda equina syndrome.

3. Nonspinal pathology (e.g., osteoarthritis of the hip joint, peripheral vascular disease) may mimic the symptoms of lumbar spinal disorders and must be considered in the differential diagnosis.

Websites

1. Low back exam (video):http://www.hss.edu/conditions_14639.asp

2. Physical examination of the cervical, thoracic, and lumbar spine (video): http://videos.med.wisc.edu/videoInfo.php?videoid=3121

3. Key points related to physical examination of the lumbar spine: http://www.wheelessonline.com/ortho/exam_of_the_lumbar_spine

4. United States Disability Examination Worksheets: http://www.vba.va.gov/BLN/21/Benefits/exams/disexm53.htm

BiBLiOGRAPHY

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

2. Apeldoorn AT, Bosselaar H, Blom-Luberti T, et al. The reliability of nonorganic sign-testing and the Waddell score in patients with chronic low back pain. Spine 2008;33:821-6.

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

4. Rainville J, Jouve C, Finno M, et al. Comparison of four tests of quadriceps strength in L3 or L4 radiculopathies. Spine 2003;28:2466-71.

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., editors. Rothman-Simeone The Spine. 5th ed. Philadelphia: Saunders; 2006, p. 169-86.

| EVALUATION OF THE SPINE TRAUMA PATIENT

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