Thoracic and Lumbar Thoracic and Lumbar Spine Special Tests and Spine Special Tests and Pathologies Pathologies Orthopedic Assessment III – Orthopedic Assessment III – Head, Spine, and Trunk with Lab Head, Spine, and Trunk with Lab PET 5609C PET 5609C
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Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.
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Thoracic and Lumbar Thoracic and Lumbar Spine Special Tests Spine Special Tests
and Pathologiesand PathologiesOrthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk
with Labwith Lab
PET 5609CPET 5609C
Clinical EvaluationClinical Evaluation
Spring Test:Spring Test: Test Positioning:Test Positioning:
Subject is proneSubject is prone Examiner stands with thumbs or hypothenar Examiner stands with thumbs or hypothenar
eminence over the spinous process of a lumbar eminence over the spinous process of a lumbar vertebraevertebrae
Action:Action: Apply a downward “springing” force through the Apply a downward “springing” force through the
spinous process of each vertebrae to assess anterior-spinous process of each vertebrae to assess anterior-posterior motionposterior motion
Positive Finding:Positive Finding: Increases or decreases in motion at one vertebrae Increases or decreases in motion at one vertebrae
compared to another (hypermobility or hypomobility)compared to another (hypermobility or hypomobility)
Clinical EvaluationClinical Evaluation
Nerve Root Nerve Root Impingement:Impingement: Narrowing of Narrowing of
Valsalva Test:Valsalva Test: Test Position:Test Position:
Patient seated, examiner standing next to patientPatient seated, examiner standing next to patient Action:Action:
Subject takes a deep breath and holds while bearing Subject takes a deep breath and holds while bearing down as if having a bowel movementdown as if having a bowel movement
Positive Finding:Positive Finding: Increased spinal or radicular pain due to Increased spinal or radicular pain due to ↑ ↑ intrathecal intrathecal
pressurepressure May be secondary to a space-occupying lesion (i.e. May be secondary to a space-occupying lesion (i.e.
herniated disc, tumor, osteophyte in lumbar canal)herniated disc, tumor, osteophyte in lumbar canal) Comments:Comments:
Increase in intrathecal pressure may result in Increase in intrathecal pressure may result in ↓ ↓ pulse, pulse, ↓ venous return, ↑ venous pressure (dizziness and/or ↓ venous return, ↑ venous pressure (dizziness and/or fainting)fainting)
Milgram Test:Milgram Test: Test Position:Test Position:
Patient supine, examiner at feet of the patientPatient supine, examiner at feet of the patient Action:Action:
Patient performs a bilateral straight leg raise to Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the height of 2 to 6 inches and is asked to hold the position for 30 secondsthe position for 30 seconds
Positive Finding:Positive Finding: Patient unable to hold position, cannot lift the Patient unable to hold position, cannot lift the
leg, or has pain with testleg, or has pain with test Implications:Implications:
Intrathecal or extrathecal pressure causing an Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar intervertebral disc to place pressure on a lumbar nerve rootnerve root
Kernig’s Test:Kernig’s Test: Test Position:Test Position:
Patient supine, examiner at side of patientPatient supine, examiner at side of patient Action:Action:
Patient performs a unilateral active straight leg Patient performs a unilateral active straight leg raise with the knee extended until pain occursraise with the knee extended until pain occurs
After pain occurs, the patient flexes the kneeAfter pain occurs, the patient flexes the knee Positive Finding:Positive Finding:
Pain in the spine and possibly radiating into Pain in the spine and possibly radiating into lower extremitylower extremity
Pain relieved when patient flexes the kneePain relieved when patient flexes the knee Implications:Implications:
Nerve root impingement secondary to bulging of Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meningesirritation of dural sheath; irritation of meninges
the cervical spine (lifts the cervical spine (lifts the head)the head)
Hip unilaterally flexed Hip unilaterally flexed (no more than 90(no more than 9000))
Knee than flexed to no Knee than flexed to no more than 90more than 9000
(+) ↑ pain with neck (+) ↑ pain with neck and hip flexion; pain and hip flexion; pain relieved when knee is relieved when knee is flexedflexed
Clinical EvaluationClinical Evaluation
Nerve Root Impingement Tests:Nerve Root Impingement Tests: Unilateral Straight Leg Raise Test Unilateral Straight Leg Raise Test
(Lasegue Test):(Lasegue Test): Test Position:Test Position:
Patient supine, examiner standing at tested Patient supine, examiner standing at tested side with the distal hand around the subject’s side with the distal hand around the subject’s heel and proximal hand on subject’s distal heel and proximal hand on subject’s distal thigh (anterior) – maintains knee extensionthigh (anterior) – maintains knee extension
Action:Action: Examiner slowly raises the leg until Examiner slowly raises the leg until
pain/tightness noted or full ROM is obtainedpain/tightness noted or full ROM is obtained Slowly lower the leg until the pain or Slowly lower the leg until the pain or
tightness resolves, at which point dorsiflex tightness resolves, at which point dorsiflex the ankle and have subject flex the neckthe ankle and have subject flex the neck
Clinical EvaluationClinical Evaluation Straight Leg Raise Straight Leg Raise
Test: Test: Positive Findings:Positive Findings:
Leg and/or low back Leg and/or low back pain occurring with pain occurring with DF and or neck DF and or neck flexion is indicative flexion is indicative of dural involvement of dural involvement and/or sciatic nerve and/or sciatic nerve irritationirritation
Lack of pain Lack of pain reproduction with DF reproduction with DF and/or neck flexion is and/or neck flexion is indicative of indicative of hamstring tightness hamstring tightness or SI pathologyor SI pathology
Clinical EvaluationClinical Evaluation
Nerve Root Impingement Tests:Nerve Root Impingement Tests: Well Straight Leg Raising Test:Well Straight Leg Raising Test:
Can be used to differentiate between Can be used to differentiate between sciatic nerve irritation or a herniated sciatic nerve irritation or a herniated intervertebral disc that is irritating the intervertebral disc that is irritating the nerve root nerve root
Test Position:Test Position: Patient supine, examiner standing at Patient supine, examiner standing at
unaffected side; one hand grasps under the unaffected side; one hand grasps under the heel while other is placed on anterior thigh heel while other is placed on anterior thigh to stabilize the leg in extensionto stabilize the leg in extension
Clinical EvaluationClinical Evaluation
Well Straight Leg Well Straight Leg Raise Test:Raise Test: Action:Action:
Examiner raises the Examiner raises the leg by flexing the leg by flexing the hip until discomfort hip until discomfort is reported (knee is reported (knee kept in full kept in full extension) extension)
Positive Finding:Positive Finding: Pain is experienced Pain is experienced
on the side opposite on the side opposite that being raisedthat being raised
Test Position:Test Position: Patient standing with feet shoulder width Patient standing with feet shoulder width
apartapart Examiner stands behind the patient, Examiner stands behind the patient,
grasping the patient’s shouldersgrasping the patient’s shoulders Action:Action:
Patient extends the spine as far as possible, Patient extends the spine as far as possible, than sidebends and rotates to affected sidethan sidebends and rotates to affected side
Examiner provides overpressure through the Examiner provides overpressure through the shoulders, supporting the patient as neededshoulders, supporting the patient as needed
Test Position:Test Position: Patient sits over edge of table; examiner is at Patient sits over edge of table; examiner is at
side of patientside of patient Action:Action:
(1) Patient slumps forward along thoracolumbar (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping spine, rounding the shoulders while keeping cervical spine neutralcervical spine neutral
(2) Patient flexes cervical spine; Clinician holds (2) Patient flexes cervical spine; Clinician holds patient in this positionpatient in this position
(3) Knee is actively extended(3) Knee is actively extended (4) Ankle is actively dorsiflexed(4) Ankle is actively dorsiflexed (5) Repeat on opposite side(5) Repeat on opposite side
Sciatic pain or Sciatic pain or reproduction of reproduction of other neurological other neurological symptomssymptoms
Implications:Implications: Impingement of Impingement of
the dural lining, the dural lining, spinal cord, or spinal cord, or nerve rootsnerve roots
Note: Patient performs ACTIVE knee extension and dorsiflexion
Clinical EvaluationClinical Evaluation Test for Patient Test for Patient
Malingering:Malingering: Malingering – medical Malingering – medical
and psychological and psychological terms that refers to an terms that refers to an individual individual fabricating/exaggeratinfabricating/exaggerating their level of g their level of symptomssymptoms
Avoiding workAvoiding work Obtaining drugsObtaining drugs Attract attention or Attract attention or
sympathysympathy
Clinical EvaluationClinical Evaluation Test for Patient Malingering:Test for Patient Malingering:
Hoover Test:Hoover Test: Test Position:Test Position:
Patient supinePatient supine Examiner at feet of patient with hands cupping Examiner at feet of patient with hands cupping
the calcaneous of each legthe calcaneous of each leg Action:Action:
Patient attempts to actively straight leg raise on Patient attempts to actively straight leg raise on the involved sidethe involved side
Positive Findings:Positive Findings: Patient does not attempt to lift the leg and Patient does not attempt to lift the leg and
examiner does NOT sense pressure from the examiner does NOT sense pressure from the uninvolved leg pressing down on the hand uninvolved leg pressing down on the hand
Patient is not attempting to perform the testPatient is not attempting to perform the test
Clinical EvaluationClinical Evaluation
Test Note: Examiner should be standing at feet of patient with their hands cupping the heels of each leg
Clinical EvaluationClinical Evaluation
Nerve Nerve Root Root LevelLevel
Sensory TestingSensory Testing
L1L1 Inguinal area (just below inguinal Inguinal area (just below inguinal ligamentligament
L2L2 Mid-thigh (medial)Mid-thigh (medial)
L3L3 Medial knee (just above superior Medial knee (just above superior pole of patella)pole of patella)
L4L4 Medial aspect of lower leg, medial Medial aspect of lower leg, medial ankle, big toeankle, big toe
L5L5 Top of foot (an/or blow head of Top of foot (an/or blow head of fibula)fibula)
Test Position: athlete supineTest Position: athlete supine Athletic Trainer Position: At Athletic Trainer Position: At
the foot of the athlete the foot of the athlete holding a blunt tool (reflex holding a blunt tool (reflex hammer)hammer)
Procedure: Rub the tool up Procedure: Rub the tool up bottom of athlete’s foot bottom of athlete’s foot starting at the calcaneus and starting at the calcaneus and ending at the great toe.ending at the great toe.
Positive test: Great toe Positive test: Great toe extends while other toes extends while other toes splay.splay.
Implications: Lesion of Implications: Lesion of upper motor neurons, may upper motor neurons, may be caused by trauma to the be caused by trauma to the brainbrain
Comments: This reflex Comments: This reflex occurs naturally in occurs naturally in newborns. However, this newborns. However, this reflex should cease quickly reflex should cease quickly after birth.after birth.
Clinical EvaluationClinical Evaluation
Erector Spinae Erector Spinae Muscle Strain:Muscle Strain: Common low back Common low back
pathologypathology MOI: MOI:
History of heavy or History of heavy or repetitive liftingrepetitive lifting
Signs/Symptoms:Signs/Symptoms: Aching backAching back Pain Pain ↑ ↑ with passive and with passive and
active flexion, resisted active flexion, resisted extensionextension
Pathology of facet joints – 40% of all chronic Pathology of facet joints – 40% of all chronic low back painlow back pain
Vague signs/symptoms:Vague signs/symptoms: Often resemble other low back pathologies (i.e. Often resemble other low back pathologies (i.e.
strain/spasm of paraspinal muscles, nerve root strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration)impingement, disc degeneration)
Involvement:Involvement: Dislocation/sublocation of facet:Dislocation/sublocation of facet:
Tends to “lock” the involved spinal segment Tends to “lock” the involved spinal segment (hypomobile vertebrae)(hypomobile vertebrae)
Facet joint syndrome: (inflammation)Facet joint syndrome: (inflammation) Causes: repetitive stress through movement or Causes: repetitive stress through movement or
Stretching and strengthening:Stretching and strengthening: Low backLow back AbdominalsAbdominals Hip flexors, hip extensors, hamstringsHip flexors, hip extensors, hamstrings
History:History: Onset – insidious or may be related to single Onset – insidious or may be related to single
episodeepisode Breakdown of disc is related to repetitive stress; Breakdown of disc is related to repetitive stress;
Last episode – final failure an annulus fibrosus to Last episode – final failure an annulus fibrosus to contain nucleus pulposuscontain nucleus pulposus
Pain characteristics – affected vertebrae; Pain characteristics – affected vertebrae; compression of spinal nerve root leads to compression of spinal nerve root leads to pain in low back, buttocks, radiating into pain in low back, buttocks, radiating into thigh, calf, heel, footthigh, calf, heel, foot
MOI – repetitive loading of discMOI – repetitive loading of disc Predisposing condition – history of lumbar Predisposing condition – history of lumbar
Lower quarter screenLower quarter screen Special Tests:Special Tests:
Straight leg raising, Well straight leg raising, Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension testsMilgram, Sciatic and femoral nerve tension tests
Welding 2 or more vertebrae togetherWelding 2 or more vertebrae together Cause of back pain (motion between Cause of back pain (motion between
vertebral segments) spinal fusion may be a vertebral segments) spinal fusion may be a way to prevent motion and stop the painway to prevent motion and stop the pain
Technique (basics):Technique (basics): Small pieces of extra bone fills space between Small pieces of extra bone fills space between
two vertebrae (pelvic bone, allograft bone)two vertebrae (pelvic bone, allograft bone) Disc removedDisc removed Wires, rods, screws, metal cages or plates may Wires, rods, screws, metal cages or plates may
be usedbe used
Clinical EvaluationClinical Evaluation
Artificial disc replacement: Disc is placed in the disc space through Artificial disc replacement: Disc is placed in the disc space through an abdominal incision; the artificial disc then maintains mobility in an abdominal incision; the artificial disc then maintains mobility in the spine and as such protects the adjacent disc from accelerated the spine and as such protects the adjacent disc from accelerated degeneration and further surgerydegeneration and further surgery
Anatomy: spinal cord ends at the lower edge of Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra the 1st lumbar vertebra
Lumbar and sacral nerve roots form a bundle Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus within the spinal canal below the conus medullarismedullaris
CES – nerves within the spinal canal have been CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function bladder, bowel and genitals do not function properlyproperly
Numbness, loss of sensation (damage usually Numbness, loss of sensation (damage usually permanent)permanent)
Congenital causes:Congenital causes: Spina bifida (abnormality in closure of spinal canal) Spina bifida (abnormality in closure of spinal canal) Tumors of the cauda equina Tumors of the cauda equina
Acquired causes of Cauda Equina Syndrome:Acquired causes of Cauda Equina Syndrome: Injury (spinal fractures) Injury (spinal fractures) Secondary to medical procedures Secondary to medical procedures
Tests for sciatic nerve irritationTests for sciatic nerve irritation Test position:Test position:
Patient supine; examiner’s one hand grasps the Patient supine; examiner’s one hand grasps the heel while other grasps the thighheel while other grasps the thigh
Action:Action: Hip and knee flexed to 90Hip and knee flexed to 9000
Knee is then extended as far as possible with Knee is then extended as far as possible with the examiner palpating the tibial portion of the the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal spacesciatic nerve as it passes behind popliteal space
Positive finding:Positive finding: Tenderness and reproduction of sciatica Tenderness and reproduction of sciatica
Spondylolysis:Spondylolysis: Defect in pars interarticularis Defect in pars interarticularis
(area between inferior and (area between inferior and superior articular facets)superior articular facets)
MOI – repetitive stressMOI – repetitive stress Unilateral or bilateral defectsUnilateral or bilateral defects Listhesis:Listhesis:
Posterior portion of the Posterior portion of the vertebrae, laminae, inferior vertebrae, laminae, inferior articular surfaces, spinous articular surfaces, spinous process separates from process separates from vertebral bodyvertebral body
Symptoms:Symptoms: Localized mow back pain Localized mow back pain
(↑ during/after activity)(↑ during/after activity) Pain with extensionPain with extension
Clinical EvaluationClinical Evaluation
Spondylolisthesis:Spondylolisthesis: Progression of spondylolysis → Progression of spondylolysis →
separation of vertebrae (superior separation of vertebrae (superior vertebrae slides anteriorly on the one vertebrae slides anteriorly on the one below it)below it) ““Decapitated Scotty dog” deformity:Decapitated Scotty dog” deformity:
Head of the dog (anterior element of Head of the dog (anterior element of vertebrae) has become detached from body vertebrae) has become detached from body (posterior element)(posterior element)
Severity – amount of anterior displacementSeverity – amount of anterior displacement Epidemiology:Epidemiology:
Most prevalent in women and adolescentsMost prevalent in women and adolescents Young gymnastsYoung gymnasts
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)
Clinical EvaluationClinical Evaluation Spondylolysis and Spondylolisthesis:Spondylolysis and Spondylolisthesis:
History:History: Onset of pain:Onset of pain:
Insidious; pain begins as an ache, ↑ to constant Insidious; pain begins as an ache, ↑ to constant painpain
Characteristics:Characteristics: Lumbar pain, radiating into buttocks and upper Lumbar pain, radiating into buttocks and upper
PROM:PROM: Hip flexion – hamstring tightnessHip flexion – hamstring tightness
RROM:RROM: Weakness of spinal erectorsWeakness of spinal erectors
Clinical EvaluationClinical Evaluation
Spondylolysis and Spondylolisthesis:Spondylolysis and Spondylolisthesis: Special Tests:Special Tests:
Pain with Spring testPain with Spring test SL stance test; straight leg raises may SL stance test; straight leg raises may
produce painproduce pain Neurological Exam:Neurological Exam:
Lower quarter screen (results typically Lower quarter screen (results typically negative)negative)
Comments:Comments: X-ray, CT, MRI (will differentiate between X-ray, CT, MRI (will differentiate between
spondylolysis and spondylolisthesis)spondylolysis and spondylolisthesis)
Clinical EvaluationClinical Evaluation
Single Leg Stance Test:Single Leg Stance Test: Test position:Test position:
Patient standing with body weight evenly Patient standing with body weight evenly distributed between the 2 feet; examiner distributed between the 2 feet; examiner stands behind pt.stands behind pt.
Action:Action: Patient lifts one leg, then places the trunk Patient lifts one leg, then places the trunk
in hyperextension; examiner may assistin hyperextension; examiner may assist Positive test:Positive test:
Pain in lumbar spine or SI areaPain in lumbar spine or SI area
Clinical EvaluationClinical Evaluation
Single Leg Stance Single Leg Stance Test:Test: Implication:Implication:
Shear forces are placed Shear forces are placed on pars interarticularis on pars interarticularis by iliopsoas pulling the by iliopsoas pulling the vertebrae anteriorlyvertebrae anteriorly
Inspection:Inspection: Levels of iliac crests, ASIS, PSISLevels of iliac crests, ASIS, PSIS
Palpation:Palpation: Pain over SI joints and PSISPain over SI joints and PSIS
Functional tests:Functional tests: Trunk flexion (with knees extended) will cause Trunk flexion (with knees extended) will cause
movement of the sacrum on the ilia (pain)movement of the sacrum on the ilia (pain) Neurological testing:Neurological testing:
Lower quarter screenLower quarter screen Special tests:Special tests:
Long sit; SI compression and distraction; Long sit; SI compression and distraction; straight leg raising; fabre; gaenslen’s; quadrantstraight leg raising; fabre; gaenslen’s; quadrant
Subject supine; examiner Subject supine; examiner stands next to subject and stands next to subject and with arms crossed, places with arms crossed, places heel of both hands on the heel of both hands on the subject’s ASISssubject’s ASISs
Subject side-lying; Subject side-lying; examiner stands next to examiner stands next to patient and places both patient and places both hands (one on top of the hands (one on top of the other) directly over the other) directly over the subject’s iliac crestsubject’s iliac crest
Increased pain indicative Increased pain indicative of SI pathology (possibly of SI pathology (possibly involving posterior SI involving posterior SI ligaments)ligaments)
Clinical EvaluationClinical Evaluation
Sacroiliac Joint Stress Test:Sacroiliac Joint Stress Test: Test position:Test position:
Subject lying prone; examiner places Subject lying prone; examiner places both hands (one on top of the other) both hands (one on top of the other) over subject’s sacrumover subject’s sacrum
Action:Action: Apply downward pressure on sacrumApply downward pressure on sacrum
Positive finding:Positive finding: Increased pain indicative of SI Increased pain indicative of SI
pathologypathology
Clinical EvaluationClinical Evaluation Patrick or FABER Test:Patrick or FABER Test:
Test position:Test position: Subject supineSubject supine
abducts, and externally abducts, and externally rotates the involved leg rotates the involved leg until the foot rests on the until the foot rests on the top of the knee of top of the knee of uninvolved lower extremity; uninvolved lower extremity; examiner slowly abducts examiner slowly abducts the involved lower the involved lower extremity towards the tableextremity towards the table
Test position:Test position: Subject supine, lying close Subject supine, lying close
to edge of table; examiner to edge of table; examiner stands at sidestands at side
Action:Action: Slide patient to edge of Slide patient to edge of
table; patient pulls far table; patient pulls far knee up to the chest; near knee up to the chest; near leg allowed to hang over leg allowed to hang over edge of tableedge of table
Examiner applies Examiner applies downward pressure on downward pressure on near leg, forcing it into near leg, forcing it into hyperextensionhyperextension
Positive finding:Positive finding: Pain in SI region Pain in SI region
indicating SI joint indicating SI joint dysfunctiondysfunction
Test position:Test position: Subject supine, both hips and knees extended; Subject supine, both hips and knees extended;
examiner standing with thumbs on subject’s medial examiner standing with thumbs on subject’s medial malleolimalleoli
Action:Action: Examiner passively flexes both hips and knees and Examiner passively flexes both hips and knees and
then fully extends and compares position of medial then fully extends and compares position of medial malleoli relative to eachothermalleoli relative to eachother
Subject slowly assumes the long-sitting position and Subject slowly assumes the long-sitting position and malleolar position is re-assessedmalleolar position is re-assessed
Positive finding:Positive finding: Leg appears longer in supine but shorter in long-Leg appears longer in supine but shorter in long-
sitting is indicative of an ipsilateral anteriorly rotated sitting is indicative of an ipsilateral anteriorly rotated iliumilium
Leg appears shorter in supine but longer in long-Leg appears shorter in supine but longer in long-sitting is indicative of an ipsilateral posteriorly sitting is indicative of an ipsilateral posteriorly rotated iliumrotated ilium
On-Field EvaluationOn-Field Evaluation
History:History: Location of pain:Location of pain:
Localized in vertebral column – disc rupture, Localized in vertebral column – disc rupture, sprain, facet pathologysprain, facet pathology
Radiating pain into extremities – spinal nerve Radiating pain into extremities – spinal nerve root pathologyroot pathology
Pain parallel to vertebral column – muscle spasmPain parallel to vertebral column – muscle spasm Peripheral symptoms:Peripheral symptoms: