Thoracic and Lumbar Spine Clinical Evaluation

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Thoracic and Lumbar Spine Clinical Evaluation

• Orthopedic Assessment III Head, Spine, and
  Trunk with Lab
• PET 5609C

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Clinical Evaluation

• History
• Location of Pain
• Pain radiating into extremities
• Peripheral paresthesia or numbness
• Result of impingement or pressure on nerve root
  exiting intervertebral foramen or dural
  irritation proximal to pain site
• Pain Locations
• Lumbar pain possible ambiguous cause
• Sacroiliac pathology pain around PSIS or
  radiating pain in hip/groin
• Piriformis spasm symptoms of sciatic nerve
  dysfunction

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Clinical Evaluation
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Clinical Evaluation

• History
• Onset of Pain
• Acute
• Chronic
• Insidious pain onset
• Note Patient may describe a single incident
  that initiated pain, although trauma is probably
  an accumulation or repetitive stresses/microtrauma

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Clinical Evaluation

• History
• Mechanism of Injury
• Movement Flexion, Extension, Lateral Bending,
  Rotation
• Blunt Trauma Direct blow to lumbar/thoracic
  area
• Contusions
• Compressive Stress
• Hyperextension of spine

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Clinical Evaluation

• History
• Pain Consistency
• Constant Pain Unyielding (does not improve with
  various position of patients spine)
• Example pathology Inflammation of dural sheath

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Clinical Evaluation

• History
• Pain Consistency
• Intermittent Pain
• Mechanical Origin certain spinal positions may
  ? or ? pain symptoms
• Compression/stretching of nerve root Increase
  pain
• Positioning (flexion, traction) lessen the
  pressure on involved structure

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Clinical Evaluation

• History
• Bowel or bladder signs
• Does the patient have any bowel or bladder
  problems?
• Incontinence Loss of bowel or bladder control
• May indicate lower nerve root lesions (cauda
  equina syndrome), or spinal cord injury
• Description urinary incontinence may range from
  occasionally leaking urine (during cough/sneeze)
  to having sudden episodes of strong urinary
  urgency

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Clinical Evaluation

• History
• Bowel or Bladder Signs
• Cauda Equina Syndrome
• Nerves within the spinal canal have been damaged
• Result nerves supplying the muscles of the
  legs, bladder, bowel and genitals do not function
  properly
• Patients experience numbness, loss of sensation
  and pain in the legs, buttocks and pelvic region
  (damage usually permanent)
• Causes
• Spina bifida (abnormality in closure of spinal
  canal)
• Tumors
• Injury (spinal fractures)
• Intravertebral disc herniation
• Vascular (blood vessel) problems or infections of
  the cauda equina

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Clinical Evaluation

• History
• History of spinal injury
• Previous injuries
• Structural degeneration
• Predisposition to injury
• Changes in activity
• Exercise habits (intensity levels, duration,
  frequency)
• Footwear, running surfaces
• New bed

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Clinical Evaluation

• General Inspection
• Frontal Curvature
• Alignment of lumbar, thoracic, cervical vertebrae
  with patient lying prone or standing
• Normal alignment straight
• Abnormal alignment
• Scoliosis lateral curvature (lumbar and/or
  thoracic spine)

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Clinical Evaluation

• General Inspection Scoliosis
• Signs and symptoms
• Uneven shoulders
• One shoulder blade appears more prominent
• Uneven waist / 1 hip higher vs. other
• Leaning to one side
• Back pain and difficulty breathing (severe
  scoliosis)
• Causes
• Idiopathic (85 of cases)
• Underlying neuromuscular disease, leg-length
  discrepancy, birth defect, fetal development
  (congenital)
• Not caused by poor posture, diet, exercise, or
  the use of backpacks

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Clinical Evaluation

• Diagnosis
• Angle X-ray
• Normal Spine (0 degrees)
• Scoliosis (gt 10 degrees)
• Complications (severe scoliosis)
• Lung and heart damage compression of rib cage
  against heart, lungs
• gt 70 degrees
• Back problems

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Clinical Evaluation

• General Inspection
• Scoliosis Test Adams Forward Bend Test
• Patient Position Standing with hands held in
  front (arms straight)
• Evaluation Procedure Patient bends forward,
  sliding hands down the front of each leg
• Positive Test
• Asymmetrical hump along lateral aspect of
  thoracolumbar spine
• One shoulder blade appears more prominent
• Uneven hips
• Implications
• Functional scoliosis scoliosis present when
  patient stands straight, disappears during
  flexion
• Structural scoliosis present during both
  standing and with flexion

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Clinical Evaluation
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Clinical Evaluation

• General Inspection
• Sagital Curvature
• Normal Alignment
• Lordotic cervical
• Kyphotic thoracic
• Lordotic lumbar
• Kyphotic sacral

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Clinical Evaluation
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Clinical Evaluation

• General Inspection
• Observation of GAIT
• Spinal pain influence on walking and running
  gait
• Slouching
• Shuffling
• Shortened gait

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Clinical Evaluation

• General Inspection
• Skin Markings
• Café-au-lait spots presence of darkened areas
  of skin pigmentation
• Normal (benign)
• Collagen disease
• Neurofibromatosis 1
• 95 of patients will display spots

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Clinical Evaluation

• General Inspection
• Skin Markings Sign of Neurofibromatosis-1
• Neurofibromatosis-1
• Autosomal dominant disease
• Characterized by formation of neurofibromas
  (tumors involving nerve tissue) in the skin,
  subcutaneous tissue, cranial nerves, and spinal
  root nerves
• Implications growth of tissue along the nerves
  puts pressure on affected nerves and cause pain
  and severe nerve damage
• Loss of nerve function (sensation, movement)

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Clinical Evaluation

• General Inspection
• Breathing patterns
• Irregular breathing (i.e. shallow respirations,
  pain)
• Injury to thoracic vertebrae
• Pressure on thoracic nerves
• Trauma to ribs, costal cartilage
• Bilateral comparison of skin folds
• Asymmetry of natural folds
• Causes muscle imbalance, ? or ? kyphosis,
  scoliosis

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Clinical Evaluation

• General Inspection
• Kyphosis
• Abnormal forward rounding of the upper back (gt 40
  to 45 degrees)
• Round back or hunchback
• Causes
• Developmental problems, degenerative diseases
  (arthritis), osteoporosis with compression
  fractures, trauma
• Severe cases
• Can affect lungs, nerves, causing pain and other
  problems

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Clinical Evaluation

• General Inspection
• Kyphosis Test Forward bend test
• Patient bends forward from the waist while ATC
  views the spine from the side
• With kyphosis, the rounding of the upper back may
  become more obvious in this position
• Postural kyphosis the deformity corrects itself
  when patient lies on their back

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Clinical Evaluation

• Postural kyphosis
• May improve on its own
• Exercises to strengthen back muscles, correct
  posture, and sleeping on a firm bed
• Structural kyphosis
• Caused by spinal abnormalities
• Scheuermann's disease
• Developmental disorder that causes a stooped
  forward or bent-over posture
• Affects between 0.5 and 8 of the general
  population
• Osteoporosis-related kyphosis
• Multiple compression fractures
• Low bone density

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Clinical Evaluation
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Clinical Evaluation

• General Inspection
• Movement and Posture
• Poor posture (standing, sitting, bending)
• Lordotic Curve
• Reduction
• Muscle spasm
• Hamstring tightness
• Increased
• Hip flexor tightness
• Abdominal weakness

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Clinical Evaluation
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Clinical Evaluation

• General Inspection
• Standing Posture
• Lateral shift in trunk and pelvis
• Nerve root impingement (lateral shift ? pressure)
• Erector Spinae Muscle Tone
• Unilateral hypertrophy or atrophy
• Fauns Beard
• Spina bifida occulta

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Clinical Evaluation

• General Inspection Spina Bifida
• Birth defect that occurs when the tissue
  surrounding the developing spinal cord doesn't
  close properly
• Spina Bifida Occulta
• Mildest form, results in a small separation in
  one or more of the vertebrae of the spine (spinal
  nerves usually not involved most patients have
  no signs/symptoms or neurological problems)
• Inspection Fauns Beard, a collection of fat, a
  small dimple or a birthmark on the newborn's skin
  above the spinal defect
• Complications
• Minor physical disabilities
• Mental strain
• Severity
• Size and location of the neural tube defect
• Does skin cover the area?
• Do the spinal nerves come out of the affected
  area of the spinal cord?

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Clinical Evaluation
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Clinical Evaluation

• Palpation Thoracic Spine
• Spinous Processes
• Supraspinous Ligaments
• Fills space between the spinous processes
• Costovertebral Junction
• Articulation between ribs and thoracic vertebrae
• Only palpable on slender individuals
• Trapezius
• Origin to insertion
• Rhomboids and levator scapulae lie deep to
  middle/upper traps
• Paravertebral Muscles
• Scapular Muscles

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• 1 Spinous Processes
• 2 Supraspinous Ligaments
• 3 Costovertebral Junction
• 4 Trapezius
• 5 Paravertebral Muscles
• 6 Scapular Muscles

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Clinical Evaluation
C7
T1
T2
T3
T4
T5
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• 1 Spinous Processes
• 2 Step-off Deformity
• 3 Paravertebral Muscles

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Clinical Evaluation

• Spondylolisthesis
• Forward slippage of a vertebrae on the one below
  it
• L4 and L5 / L5 and S1
• Affects 5-6 of males, 2-3 of females
• Causes
• Strenuous physical activity (weightlifting,
  gymnastics, football)
• Types
• Developmental
• May exist at birth, or may develop during
  childhood (generally not noticed until later in
  childhood/adult life)
• Acquired
• Degeneration caused by the daily stresses that
  are put on spine (i.e. carrying heavy items,
  physical sports)
• Connections between the vertebrae weaken
• Single or repeated force

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Clinical Evaluation

• Spondylolisthesis
• Grade 1
• 25 of vertebral body has slipped forward 
• Grade 2
• 50
• Grade 3
• 75
• Grade 4
• 100
• Grade 5
• Vertebral body completely fallen off
  (i.e.,spondyloptosis)

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Clinical Evaluation

• Symptoms
• May be asymptomatic
• Low back pain (especially after exercise)
• ? lordosis
• Pain/weakness in one or both legs
• ? ability to control bowel/ bladder functions
• Tight hamstrings
• Advanced spondylolisthesis changes may occur in
  the way patient stands/walks

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Clinical Evaluation

• Palpation Sacrum and Pelvis
• Median sacral crests
• Iliac crests
• Palpate laterally from PSIS to find iliac crests
  and anteriorly to locate ASIS (level of symmetry)
• Posterior superior iliac spine
• Gluteals
• Ischial tuberosity
• Greater trochanter
• Sciatic nerve
• Place thumb on ischial tuberosity and 3rd finger
  on the PSIS. 2nd finger will fall into sciatic
  notch (nerve most superficial as it passes by
  ischial tuberosity)
• Pubic symphysis

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• 1 Median sacral crests
• 2 Iliac crests
• 3 PSIS
• 4 Gluteal muscles
• 5 Ischial tuberosity
• 6 Greater trochanter
• 7 Sciatic nerve
• 8 Pubic symphysis

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• 1 Iliac crest
• 2 Tensor fascia latae
• 3 Gluteus medius
• 4 Iliotibial band
• 5 Greater trochanter
• 6 Trochanteric bursa

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• 1 Pubis
• 2 ASIS
• 3 AIIS
• 4 Sartorius
• 5 Rectus femoris

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Clinical Evaluation

• Active Range of Motion
• Flexion and Extension
• Measured with patient standing
• Distance from the fingertips to the floor can be
  measured (accuracy affected by tightness of
  hamstrings and calf muscles and scapular
  protraction)
• Gravity assists with movement
• More accurate than hook-lying position
• Abdominal muscles have to overcome weight of the
  trunk

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Clinical Evaluation

• Active Range of Motion
• Lateral Bending
• Patient standing (feet shoulder width apart and
  the hand opposite the direction of the movement
  resting on the ilium)
• Patient bends trunk laterally (attempt to tough
  fingertips to the ground)
• Distance between the ground and fingertips is
  measured
• Rotation
• Patient is sitting position (stabilizes pelvis
  and lower extremity)
• Patient rotates shoulder girdles and spinal
  column (attempt to look behind ones back)
• Movement primarily occurs in thoracic spine

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Clinical Evaluation

• Passive Range of Motion
• Flexion
• Patient in hook-lying position
• Examiner brings the knees to the chest by lifting
  under the knees and thighs and flexing the hip
  and thoracic spine
• Extension
• Patient prone (hands flat on table at shoulder
  level push-up position)
• Patient extends arms, lifting the torso (hips and
  legs remain of table)
• Rotation
• Patient in hook-lying position
• Patients pelvis and legs are rotated to bring
  lateral portion of the knee towards the table
  (shoulders remain flat)

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Spinal Ligaments Stressed During Passive Range of
Motion Testing
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Clinical Evaluation

• Beevors Sign
• Test for thoracic nerve inhibition
• Patient performs an abdominal curl-up from
  hook-lying position
• Normal Findings abdominal muscles receive
  concurrent innervation from T5-T12 nerve roots
  (umbilicus does not move)
• Positive Test umbilicus is pulled toward the
  head
• Characteristic of spinal cord injury between T6
  and T10 levels
• Upper abdominal muscles (rectus abdominis) are
  intact at the top of the abdomen but weak at the
  lower portion, patient is asked to do a sit up
  only the upper muscles contract (umbilicus pulled
  toward the head)

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Clinical Evaluation

• Resistive Range of Motion
• Flexion
• Patient position supine with knees flexed and
  feet flat on table
• Stabilization pelvis
• Resistance applied to the superior sternum as
  patient lifts the scapulae off the table
• Muscles tested rectus abdominis, internal
  oblique, external oblique

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Clinical Evaluation

• Resisted Range of Motion
• Extension
• Patient position prone with arms interlocked
  behind the head
• Stabilization lower lumbar region
• Resistance applied to upper thoracic spine as
  patient lifts head, chest, and arms off table
• Muscles tested iliocostalis lumborum,
  iliocostalis thoracis, longissimus thoracis,
  spinalis thoracis, semispinalis thoracis,
  rotators, latissimus dorsi

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Clinical Evaluation

• Resisted Range of Motion
• Rotation
• Patient position supine (hands interlocked
  behind head)
• Stabilization opposite ASIS
• Resistance anterior aspect of shoulder as it is
  rotated off the table
• Muscles tested internal oblique, external
  oblique (opposite side), rotators, multifidi