Thoracic and Lumbar Spine Special Tests and Pathologies

1. Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. Clinical Evaluation • Spring Test: • Test Positioning: • Subject is prone • Examiner stands with thumbs or hypothenar eminence over the spinous process of a lumbar vertebrae • Action: • Apply a downward “springing” force through the spinous process of each vertebrae to assess anterior-posterior motion • Positive Finding: • Increases or decreases in motion at one vertebrae compared to another (hypermobility or hypomobility)

3. Nerve Root Impingement: Narrowing of intervertebral foramen: Stenosis Facet joint degeneration Herniated intervertebral disc Clinical Evaluation

4. Clinical Evaluation

5. Clinical Evaluation • Nerve Root Impingement Tests: • Valsalva Test: • Test Position: • Patient seated, examiner standing next to patient • Action: • Subject takes a deep breath and holds while bearing down as if having a bowel movement • Positive Finding: • Increased spinal or radicular pain due to ↑ intrathecal pressure • May be secondary to a space-occupying lesion (i.e. herniated disc, tumor, osteophyte in lumbar canal) • Comments: • Increase in intrathecal pressure may result in ↓ pulse, ↓ venous return, ↑ venous pressure (dizziness and/or fainting)

6. Clinical Evaluation • Nerve Root Impingement Tests: • Milgram Test: • Test Position: • Patient supine, examiner at feet of the patient • Action: • Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the position for 30 seconds • Positive Finding: • Patient unable to hold position, cannot lift the leg, or has pain with test • Implications: • Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar nerve root

7. Clinical Evaluation • Nerve Root Impingement Tests: • Kernig’s Test: • Test Position: • Patient supine, examiner at side of patient • Action: • Patient performs a unilateral active straight leg raise with the knee extended until pain occurs • After pain occurs, the patient flexes the knee • Positive Finding: • Pain in the spine and possibly radiating into lower extremity • Pain relieved when patient flexes the knee • Implications: • Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meninges

8. Nerve Root Impingement Tests: Kernig/Brudzinski Test: Patient actively flexes the cervical spine (lifts the head) Hip unilaterally flexed (no more than 900) Knee than flexed to no more than 900 (+) ↑ pain with neck and hip flexion; pain relieved when knee is flexed Clinical Evaluation

9. Clinical Evaluation • Nerve Root Impingement Tests: • Unilateral Straight Leg Raise Test (Lasegue Test): • Test Position: • Patient supine, examiner standing at tested side with the distal hand around the subject’s heel and proximal hand on subject’s distal thigh (anterior) – maintains knee extension • Action: • Examiner slowly raises the leg until pain/tightness noted or full ROM is obtained • Slowly lower the leg until the pain or tightness resolves, at which point dorsiflex the ankle and have subject flex the neck

10. Straight Leg Raise Test: Positive Findings: Leg and/or low back pain occurring with DF and or neck flexion is indicative of dural involvement and/or sciatic nerve irritation Lack of pain reproduction with DF and/or neck flexion is indicative of hamstring tightness or SI pathology Clinical Evaluation

11. Clinical Evaluation • Nerve Root Impingement Tests: • Well Straight Leg Raising Test: • Can be used to differentiate between sciatic nerve irritation or a herniated intervertebral disc that is irritating the nerve root • Test Position: • Patient supine, examiner standing at unaffected side; one hand grasps under the heel while other is placed on anterior thigh to stabilize the leg in extension

12. Well Straight Leg Raise Test: Action: Examiner raises the leg by flexing the hip until discomfort is reported (knee kept in full extension) Positive Finding: Pain is experienced on the side opposite that being raised Clinical Evaluation

13. Clinical Evaluation • Nerve Root Impingement Tests: • Quadrant Test: • Test Position: • Patient standing with feet shoulder width apart • Examiner stands behind the patient, grasping the patient’s shoulders • Action: • Patient extends the spine as far as possible, than sidebends and rotates to affected side • Examiner provides overpressure through the shoulders, supporting the patient as needed

14. Clinical Evaluation • Nerve Root Impingement Tests: • Quadrant Test: • Positive Findings: • Reproduction of patient’s symptoms • Implications: • Radicular pain indicates compression of the intervertebral foramina that impinges on the lumbar nerve roots • Local pain (not radiating) indicates facet joint pathology • Symptoms isolated to the area of the PSIS may indicate SI joint dysfunction

15. Clinical Evaluation • Nerve Root Impingement Tests: • Slump Test: • Test Position: • Patient sits over edge of table; examiner is at side of patient • Action: • (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping cervical spine neutral • (2) Patient flexes cervical spine; Clinician holds patient in this position • (3) Knee is actively extended • (4) Ankle is actively dorsiflexed • (5) Repeat on opposite side

16. Slump Test: Positive Findings: Sciatic pain or reproduction of other neurological symptoms Implications: Impingement of the dural lining, spinal cord, or nerve roots Clinical Evaluation Note: Patient performs ACTIVE knee extension and dorsiflexion

17. Test for Patient Malingering: Malingering – medical and psychological terms that refers to an individual fabricating/exaggerating their level of symptoms Financial compensation (fraud) Avoiding work Obtaining drugs Attract attention or sympathy Clinical Evaluation

18. Clinical Evaluation • Test for Patient Malingering: • Hoover Test: • Test Position: • Patient supine • Examiner at feet of patient with hands cupping the calcaneous of each leg • Action: • Patient attempts to actively straight leg raise on the involved side • Positive Findings: • Patient does not attempt to lift the leg and examiner does NOT sense pressure from the uninvolved leg pressing down on the hand • Patient is not attempting to perform the test

19. Clinical Evaluation Test Note: Examiner should be standing at feet of patient with their hands cupping the heels of each leg

20. Clinical Evaluation Lower Quarter Neurological Screen

22. Clinical Evaluation Lower Quarter Neurological Screen

23. Clinical Evaluation Lower Quarter Neurological Screen

25. Babinkski’s Test: Test Position:  athlete supine Athletic Trainer Position:  At the foot of the athlete holding a blunt tool (reflex hammer) Procedure:  Rub the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe. Positive test: Great toe extends while other toes splay. Implications:  Lesion of upper motor neurons, may be caused by trauma to the brain Comments:  This reflex occurs naturally in newborns.  However, this reflex should cease quickly after birth. Clinical Evaluation

26. Erector Spinae Muscle Strain: Common low back pathology MOI: History of heavy or repetitive lifting Signs/Symptoms: Aching back Pain ↑ with passive and active flexion, resisted extension Neurological Evaluation: Negative results Clinical Evaluation

27. Clinical Evaluation • Facet Joint Dysfunction: • Pathology of facet joints – 40% of all chronic low back pain • Vague signs/symptoms: • Often resemble other low back pathologies (i.e. strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration) • Involvement: • Dislocation/sublocation of facet: • Tends to “lock” the involved spinal segment (hypomobile vertebrae) • Facet joint syndrome: (inflammation) • Causes: repetitive stress through movement or loading • Degeneration: (arthritis) • Causes: undefined history • ↓ intervertebral foramen size (nerve root impingement)

28. Clinical Evaluation • Facet Joint Dysfunction: • History: • Onset – insidious • Pain characteristics – localized • MOI – extension, rotation, lateral bending of vertebrae • Predisposing conditions – repeated motions of spinal extension, rotation, lateral bending • Inspection: • Patient may assume posture that ↓ pressure on affected facets • Palpation: • Possible local muscle spasm (paravertebral muscles)

29. Facet Joint Dysfunction: Ligamentous Tests: Spring Test – pain, ↓ motion Neurological Tests: Not applicable unless secondary nerve root impingement occurs Special Tests: Quadrant Test (+) Intervertebral disc lesions (-) Clinical Evaluation

30. Clinical Evaluation • Facet Joint Dysfunction: • Initial Treatment: • NSAIDs • Instruct patient to avoid postures/movements that irritate facets • Modalities – moist heat, e-stim, ice to ↓ muscle spasm • Therapeutic Exercises: • Stretching and strengthening: • Low back • Abdominals • Hip flexors, hip extensors, hamstrings

31. Intervertebral Disc Lesions: Disc Degeneration: Loss of water from nucleus pulposus ↓ cushioning ability ↑ stress load on annulus fibrosus Small tears occur to annulus (scar tissue formation – not as strong as normal tissue) Bulging of nucleus pulposus Clinical Evaluation

32. Intervertebral Disc Herniation: Extrusion of nucleus pulposus through annulus fibrosus Impingement/pressure on nerve root below affected disc Sequestrated – nuclear material breaks away from rest of disc Clinical Evaluation

33. MRI lumbar image: L5/S1 disc has suffered a 9mm disc extrusion (red arrow) that is not contained by the PLL L4/5 disc has suffered a smaller 4mm disc protrusion (green arrow) that is contained by the PLL L3/4 (blue arrow) is completely normal and has no disc material projecting posteriorly into the epidural space Note: L3/4 disc is white in color, which indicates it is non-degenerated (i.e., full of water and healthy proteoglycan) Herniated discs (L4/5 & L5/S1) are "black" which indicates disc desiccation (lack of water and proteoglycan)

34. Clinical Evaluation

35. Clinical Evaluation • Lumbar Disc Degeneration: • History: • Onset – insidious or may be related to single episode • Breakdown of disc is related to repetitive stress; Last episode – final failure an annulus fibrosus to contain nucleus pulposus • Pain characteristics – affected vertebrae; compression of spinal nerve root leads to pain in low back, buttocks, radiating into thigh, calf, heel, foot • MOI – repetitive loading of disc • Predisposing condition – history of lumbar spine trauma

36. Clinical Evaluation • Lumbar Disc Degeneration: • Inspection: • Slow GAIT • Flattened lumbar spine • Changes in body position – guarded and painful • Sitting → standing / sitting → lying • Changes in disc pressure • Standing position: • Lateral shift away from side of leg pain • Palpation: • Musculature spasm

37. Clinical Evaluation • Lumbar Disc Degeneration: • Functional Tests: • Limited ROM in all directions • Movement in one direction may relieve or ↓ symptoms • Neurological Tests: • Lower quarter screen • Special Tests: • Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension tests • Diagnostic Tests: • MRI

38. Clinical Evaluation • Intervertebral Disc Degeneration: Surgery • Spinal Fusion: • Welding 2 or more vertebrae together • Cause of back pain (motion between vertebral segments) spinal fusion may be a way to prevent motion and stop the pain • Technique (basics): • Small pieces of extra bone fills space between two vertebrae (pelvic bone, allograft bone) • Disc removed • Wires, rods, screws, metal cages or plates may be used

39. Clinical Evaluation

40. Clinical Evaluation Artificial disc replacement: Disc is placed in the disc space through an abdominal incision; the artificial disc then maintains mobility in the spine and as such protects the adjacent disc from accelerated degeneration and further surgery

41. Clinical Evaluation • Cauda Equina Syndrome: • Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra • Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus medullaris • CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function properly • Numbness, loss of sensation (damage usually permanent) • Congenital causes: • Spina bifida (abnormality in closure of spinal canal) • Tumors of the cauda equina • Acquired causes of Cauda Equina Syndrome: • Injury (spinal fractures) • Secondary to medical procedures

42. Femoral Nerve Stretch Test: Tests for nerve root impingement at L2, L3, L4 Test position: Patient prone with a pillow under the abdomen; examiner at side of patient Action: Examiner passively extends hip while keeping knee flexed to 900 Positive test: Pain in anterior and lateral thigh Clinical Evaluation

43. Sciatica: General term for any inflammation involving sciatic nerve Causes: Lumbar disc herniation SI joint dysfunction Scar tissue around nerve root Nerve root inflammation Spinal stenosis Synovial cysts Cancerous or noncancerous tumors Clinical Evaluation

44. Sciatica: Signs and Symptoms: Radiating pain Muscular weakness Special Tests: Straight leg raise test Tension sign Treatment and Rehab: Resolve pathology that is irritating nerve Oral anti-inflammatory meds / corticosteroids Exercises for strength / ROM Clinical Evaluation

45. Clinical Evaluation • Tension Sign: • Tests for sciatic nerve irritation • Test position: • Patient supine; examiner’s one hand grasps the heel while other grasps the thigh • Action: • Hip and knee flexed to 900 • Knee is then extended as far as possible with the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal space • Positive finding: • Tenderness and reproduction of sciatica symptoms

46. Clinical Evaluation

47. Clinical Evaluation • Bowstring Test: (Cram Test) • Test position: • Patient supine • Action: • Examiner performs a passive straight leg raise on involved side • If subjects reports radiating pain, examiner flexes the subject’s knee to approximately 200 in attempt to reduce pain • Pressure than applied to popliteal area to reproduce radicular pain • Positive finding: • Painful radicular reproduction with popliteal compression • Indicates sciatic nerve tension

48. Spondylolysis: Defect in pars interarticularis (area between inferior and superior articular facets) MOI – repetitive stress Unilateral or bilateral defects Listhesis: Posterior portion of the vertebrae, laminae, inferior articular surfaces, spinous process separates from vertebral body “Collared Scotty dog” deformity Symptoms: Localized mow back pain (↑ during/after activity) Pain with extension Clinical Evaluation

49. Clinical Evaluation • Spondylolisthesis: • Progression of spondylolysis → separation of vertebrae (superior vertebrae slides anteriorly on the one below it) • “Decapitated Scotty dog” deformity: • Head of the dog (anterior element of vertebrae) has become detached from body (posterior element) • Severity – amount of anterior displacement • Epidemiology: • Most prevalent in women and adolescents • Young gymnasts

50. Lateral view of the lumbar spine: Bilateral break in the pars interarticularis (spondylolysis - black arrow) L5 vertebral body (red arrow) has slipped forward on the S1 vertebral body (blue arrow – spondylolisthesis) Normal pars interarticularis - white arrow.Degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 (Grade1-Grade 2 spondylolisthesis)