Dr. Michael P. Gillespie

1
Intro to Spinal Orthopedic Tests

• Dr. Michael P. Gillespie

2
Vertebrobasilar Circulation Assessment

• Vascular Insufficiency may be aggravated by
  positional change in the cervical spine.
• Assessment of the vertebrobasilar circulation
  must be done if cervical adjustment or
  manipulation is to be performed.

3
Predispositions to Cerebrovascular Accidents

• Headaches, migraine
• Dizziness
• Sudden severe head or neck pain
• Hypertensive

4
Predispositions to Cerebrovascular Accidents

• Cigarette smoking
• Oral Contraceptives
• Obesity
• Diabetes

5
Cerebrobasilar Testing

• Positional change in the cervical spine
  compresses the vertebral artery at the
  atlantoaxial junction on the side opposite of
  rotation.
• In the normal patient, the diminished blood flow
  does not cause any neurological symptoms, such as
  dizziness, nausea, tinnitus, faintness, or
  nystagmus.

6
Clinical Signs and Symptoms of Cerebrovasular
Episodes

• Vertigo, dizziness, giddiness, light-headedness
• Drop attacks, loss of consciousness
• Diplopia
• Dysarthria

7
Clinical Signs and Symptoms of Cerebrovasular
Episodes

• Dysphagia
• Ataxia of gait
• Nausea, vomiting
• Numbness on one side of the face
• Nystagmus

8
Barre-Lieou Sign

• Procedure Patient rotates head from one side to
  the other.
• Positive Test Vertigo, dizziness, visual
  blurring, nausea, faintness, nystagmus.
• Structure affected Vertebral artery on the same
  side of head rotation. Consider patency of the
  carotid arteries and the communicating cerebral
  artery circle.

9
Barre-Lieou Sign
10
Vertebrobasilar Artery Functional Maneuver

• Procedure Palpate and auscultate the carotid
  arteries for pulsations and bruits. Instruct the
  patient to rotate and hyperextend the head.

11
Vertebrobasilar Artery Functional Maneuver

• Positive Test If pulsation or bruits are
  present at either the carotid or subclavian
  arteries the test is positive.
• Structures Affected It may indicate stenosis or
  compression of the carotid or subclavian arteries.

12
Vertebrobasilar Artery Functional Maneuver
13
Dekleyns Test

• Procedure Patient supine, head off table.
  Instruct pt. to hyperextend and rotate head.
  Hold 15 to 30 seconds. Repeat opposite.
• Positive Test Vertigo, dizziness, visual
  blurring, nausea, faintness, and nystagmus.
• Structures Affected Vertebral, basilar, or
  carotid artery stenosis or compression.

14
Dekleyns Test
15
Clinical Signs and Symptoms of Cervical Strain or
Sprain

• Cervical and upper back pain
• Cervical and upper back stiffness
• Cervical and upper trapezius tightness
• Reduced cervical range of motion
• Cervical extensor spasm

16
Differentiating Between Strain and Sprain

• Cervical strain is an irritation and spasm of the
  muscles of the cervical spine with or without
  partial muscle fiber tearing.
• Cervical sprain is a wrenching of the joints of
  the cervical spine with partial tearing of its
  ligaments.

17
Categories of Strain

• Mild Slight disruption of muscle fibers with no
  appreciable hemorrhage and minimal amounts of
  swelling and edema.

18
Categories of Strain

• Moderate Laceration of muscle fibers with an
  appreciable amount of hemorrhage into the
  surrounding tissues and a moderate amount of
  swelling and edema.
• Severe Complete disruption of the muscle tendon
  unit, possibly with tearing of the tendon from
  the bone or a rupture of the muscle through its
  belly.

19
Categories of Sprain

• Mild Slight tears of a few ligamentous fibers.
• Moderate More sever tearing of ligamentous
  fibers but not complete separation of the
  ligament.

20
Categories of Sprain

• Severe Complete tearing of a ligament from its
  attachments.
• Avulsion A ligament that attaches to a bone is
  pulled loose with a fragment of that bone.

21
ODonoghues Maneuver

• Procedure Patient seated. Put the cervical
  spine through resisted range of motion, then
  through passive range of motion.
• Positive Test Pain during resisted range of
  motion or isometric muscle contraction signifies
  muscle strain. Pain during passive range of
  motion may indicate a sprain of any of the
  cervical ligaments.

22
ODonoghues Maneuver

• Structures Affected Cervical spinal muscles
  and/or cervical spinal ligaments.
• Since resisted range of motion mainly stresses
  muscles and passive range of motion mainly
  stresses ligaments, you should be able to
  determine between strain and sprain or a
  combination thereof.

23
ODonoghues Maneuver
24
Spinal Percussion Test

• Procedure Patient seated. Head slightly
  flexed, percuss the spinous process and
  associated musculature of each cervical vertebrae
  with a reflex hammer.

25
Spinal Percussion Test

• Positive Test Local pain may be a fractured
  vertebra with no neurological compromise.
  Radicular pain may be a fractured vertebra with
  neurological compromise or a disc lesion with
  neurological compromise. A ligamentous sprain
  could also elicit pain upon percussion of the
  spinous processes.

26
Spinal Percussion Test
27
Rusts Sign

• Procedure A patient with severe injury to the
  upper cervical spine will grasp the head with
  both hands to support the weight of the head on
  the cervical spine. The supine patient will
  support the head while attempting to rise.
• Positive Sign The patient stabilizes the head.
  It might include slight traction.

28
Rusts Sign

• Structures Affected This could represent severe
  muscular strain, ligamentous instability,
  posterior disc defect, upper cervical fracture,
  or dislocation.

29
Rusts Sign
30
Cervical Instability Clinical Signs and Symptoms

• Severe cervical pain.
• Patient stabilizing the head.
• Little or no cervical motion.
• Severe cervical muscle spasm.
• Upper extremity neurological dysfunction.
• Lower extremity neurological dysfunction.

31
Space-Occupying Lesions

• Clinical Signs and Symptoms
• Cervical pain.
• Upper extremity neurological symptoms.
• Lower extremity neurological symptoms.

32
Valsalvas Maneuver

• Procedure Have the patient bear down as if
  defecating and focus the bulk of the stress on
  the cervical spine. Ask if the patient feels
  pain and have them point to the location.

33
Valsalvas Maneuver

• Positive Test Local pain with increased
  pressure could indicate a space-occupying lesion
  (e.g. disc defect, mass, osteophyte) in the
  cervical canal or foramen.

34
Valsalvas Maneuver
35
Dejerines Sign

• Procedure Patient seated. Instruct them to
  cough, sneeze, and bear down as if defecating
  (Valsalvas maneuver).
• Positive Test Local pain or pain radiating to
  the shoulders or upper extremities indicates an
  increase in intrathecal pressure.
• Structures Affected Space-occupying lesion.

36
Cervical Neurological Compression and Irritation

• Clinical Signs and Symptoms
• Cervical pain.
• Upper extremity radicular pain.
• Loss of upper extremity sensation.
• Loss of upper extremity reflexes.
• Loss of upper extremity muscle strength.

37
Foraminal Compression Test

• Procedure Patient seated. Exert strong
  downward pressure on the head. Repeat with b/l
  rotation.
• Positive Test Local pain may indicate foraminal
  encroachment without nerve root pressure or
  apophyseal capsulitis. Radicular pain may
  indicate pressure on a nerve root.

38
Foraminal Compression Test
39
Jacksons Compression

• Procedure Laterally flex the head and exert
  strong downward pressure. Perform b/l.
• Positive Test Local pain may indicate foraminal
  encroachment without nerve pressure or apophyseal
  joint pathology. Radicular pain may indicate
  pressure on a nerve root.

40
Jacksons Compression
41
Spurlings Test

• Procedure Laterally flex the patients head and
  gradually apply strong downward pressure. If no
  pain is elicited, put the patients head in a
  neutral position and deliver a vertical blow to
  the uppermost portion of the patients head.

42
Spurlings Test

• Positive Test Local pain indicates facet joint
  involvement. Radicular pain indicates nerve root
  pressure.

43
Spurlings Test
44
Distraction Test

• Procedure Grasp beneath the mastoid processes
  and press up on the patients head. This removes
  the weight of the patients head on the neck.

45
Distraction Test

• Positive Test If local pain increases, suspect
  muscle strain, spasm, ligamentous sprain, or
  facet capsulitis. Relief of radicular pain
  indicates either foraminal encroachment or a disc
  defect.

46
Distraction Test
47
Shoulder Abduction Test (Bakodys Sign)

• Procedure The patient should abduct the arm and
  place the hand on top of the head.
• Positive Test A decrease or relief of the
  patients symptoms indicates a cervical
  extradural compression problem (i.e. herniated
  disc, epidural vein compression, or nerve root
  compression).

48
Shoulder Abduction Test (Bakodys Sign)
49
Thoracic Spine
50
Thoracic Cage Anterior
51
Thoracic Cage Posterior
52
Parathoracic Musculature
53
Thoracic Musculature
54
Adams Position

• Procedure Patient standing. Stand directly
  behind and inspect for scoliosis, hyperkyphosis,
  or kyphoscoliosis. Next. Patient should flex
  forward at hips. Inspect again.
• Positive Test
• If scoliosis, hyperkyphosis, or kyphoscoliosis
  reduces with forward bending poor posture,
  overdevelopment of unilateral spinal and/or upper
  extremity musculature, nerve root compromise, leg
  length deficiency, or hip contracture.

55
Adams Position

• If scoliosis, hyperkyphosis, or kyphoscoliosis
  does not reduce with forward bending structural
  deformity (i.e. hemivertebra, compression
  fracture) or idiopathic scoliosis.

56
Adams Position
57
Spinal Percussion

• Procedure Patient seated, head slightly flexed,
  percuss the spinous processes and associated
  musculature.
• Positive Test
• Local pain may indicate a fractured vertebra
  without neurological compromise or ligamentous
  sprain.
• Radicular pain may indicate a fractured vertebra
  with neurological compromise or a disc defect
  with neurological compromise.

58
Spinal Percussion
59
Sternal Compression

• Procedure Patient supine. Push down on
  sternum.
• Positive Test Pressure on the sternum
  compresses the lateral borders of the ribs. If a
  fracture is present here, pain will be produced
  or exacerbated.
• Note If trauma has occurred and you suspect a
  fractured rib, radiographs should be performed
  first before performing this test.

60
Sternal Compression
61
Beevors Sign

• Procedure Patient supine. Patient should hook
  fingers behind neck and raise the head towards
  the feet. Mimic a sit-up.

62
Beevors Sign

• Positive Test
• The umbilicus will not move in a patient with not
  thoracic root lesion.
• Umbilicus moves superiorly bilateral T10 T12
  lesion
• Umbilicus moves superiorly and laterally
  Unilateral T10 T12 nerve root lesion on
  opposite side.
• Umbilicus moves inferiorly bilateral T7 T10
  nerve root lesion.
• Umbilicus moves inferiorly and laterally
  Unilateral T7 T10 nerve root lesion of the
  opposite side.

63
Beevors Sign
64
Schepelmanns Sign

• Procedure Seated patient. Flex at waist to
  right and left.
• Positive Test
• Pain on side of lateral bending intercostal
  neuritis.
• Pain on opposite side of lateral bending
  fibrous inflammation of the pleura or intercostal
  sprain.

65
Schepelmanns Sign
66
Chest Expansion

• Procedure Patient seated. Place a tape measure
  around the patients chest at the level of the
  nipple. Instruct patient to exhale and record
  the measurement. Instruct the patient to inhale
  maximally and record the measurement.

67
Chest Expansion

• Positive Test
• Normal chest expansion for a man is 2 inches or
  more.
• Normal chest expansion for a woman is 1 inch or
  more.
• A decrease in chest expansion indicates an
  ankylosing condition at the costotransverse or
  costovertebral articulation.

68
Chest Expansion
69
Lumbar Spine

• Orthopedic Tests

70
Lumbar Anatomy
71
Erector Spinae Group
72
Quadratus Lumborum
73
Gluteal Muscles
74
Spinal Percussion Test

• Procedure Patient seated. Bent slightly
  forward. Tap the spinous processes and
  associated musculature with a reflex hammer.
• Positive Test Local pain fracture without
  neurological compromise. Radicular pain
  fracture or disc defect with neurological
  compromise. Pain in paraspinal musculature
  muscle strain.

75
Spinal Percussion Test
76
Referred Pain Vs. Radicular Pain

• Lower extremity pain may be referred from
  lumbopelvic tissues or viscera. It may also be
  radicular pain from the nerve roots of the spine.
• Referred pain patterns the spinal pain is more
  aggravating than the lower extremity pain.
  Referred pain is poorly localized and dull.
• Radicular pain patterns the leg pain is more
  aggravating than the spinal pain. Radicular pain
  is sharp and well localized.

77
Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Neurogenic radicular lower extremity pain may be
  caused by any one of several factors.
• Tension, irritation, or compression of a lumbar
  nerve root or roots can cause radicular pain.

78
Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Intraspinal canal compressions disc lesions,
  spinal stenosis, degenerative disc disease,
  hypertrophic changes, malignancy.
• Extraspinal canal compressions muscle
  dysfunction, extradural defects, masses.

79
Lumbar Nerve Root Sciatic Nerve
Irritation/Compression

• Clinical Signs and Symptoms
• Lower back pain
• Lower extremity radicular pain
• Loss of lower extremity reflexes
• Loss of lower extremity muscle strength
• Loss of lower extremity sensation

80
Straight Leg Raising Test

• Procedure Patient supine. Raise the patients
  leg to a point of pain or 90 , whichever comes
  first.

81
Straight Leg Raising Test

• Positive Test This test stresses the sciatic
  nerve and spinal nerve roots L5, S1, and S2.
• Pain after 70 of hip flexion lumbar joint
  pain.
• Pain at 35 to 70 sciatic nerve roots tense
  pain due to IVD pathology.
• Pain between 0 to 35 extradural sciatic
  involvement (spastic piriformis, SI joint
  lesion).
• Dull posterior thigh pain tight hamstring.

82
Straight Leg Raising Test
83
Antalgic Lean Sign

• Procedure Observe the patient while standing.
• Patients with disc protrusions that place
  pressure on a nerve root will lean in a direction
  that reduces the mechanical pressure on the disc.

84
Antalgic Lean (Disc protrusion lateral to nerve
root)

• Positive Sign If the disc protrusion is lateral
  to the nerve root, the patient will lean away
  from the side of pain.
• Leaning away pulls the nerve root medially away
  from the disc defect and relieves pain.

85
Antalgic Lean (Disc protrusion lateral to nerve
root)
86
Antalgic Lean (Disc protrusion medial to nerve
root)

• Positive Sign If the disc protrusion is medial
  to the nerve root, the patient will lean toward
  the side of pain.
• Leaning towards the side of the lesion pulls the
  nerve laterally away from the disc defect,
  reducing pressure on the nerve root.

87
Antalgic Lean (Disc protrusion medial to nerve
root)
88
Antalgic Lean (Disc protrusion central to nerve
root)

• Positive Sign If the disc protrusion is central
  to the nerve root, the patient may assume a
  flexed posture.
• Leaning forward puts the posterior portion of the
  disc under traction, which can reduce the surface
  area of the disc that comes into contact with the
  nerve.

89
Antalgic Lean (Disc protrusion central to nerve
root)
90
Kemps Test

• Procedure Patient seated or standing.
  Stabilize the PSIS with one hand. Reach around
  the patient with the other hand and passively
  bend the dorsolumbar spine obliquely backward.
• Positive Test Pain in the lower back is a
  positive test for lumbar spasm or facet
  capsulitis. Radicular pain suggests a disc
  lesion.

91
Kemps Test
92
Space-Occupying Lesions

• Space-occupying lesions can consist of the
  following
• Disc defect, degenerative change, synovial cyst,
  fracture, tumor, or some combination of these
  factors.
• Space-occupying lesions can lead to spinal
  stenosis.
• Narrowing of the tubular structures of the spine.
• Naorrowing of the central canal, lateral recess,
  or intervertebral foramen.

93
Space-Occupying Lesions

• Clinical Signs and Symptoms
• Lower back pain
• Lower extremity radicular pain
• Lower extremity weakness
• Loss of lower extremity reflexes
• Loss of lower extremity sensation

94
Valsalvas Maneuver

• Procedure Instruct the seated patient to bear
  down as if straining at stool. Concentrate the
  stress at the lumbar region. Ask if pain is
  increased and have the patient point to it.
• Positive Test The test increases intrathecal
  pressure.
• Positive test indicates a space-occupying lesion.
  

95
Valsalvas Maneuver
96
Dejerines Triad

• Procedure Patient seated. Instruct the patient
  to cough, sneeze, and bear down as if straining
  at stool.
• Positive Test Increased local pain suggests a
  space-occupying lesion.

97
Lumbar Vs. Sacroiliac Joint Involvement

• Lumbar and/or radicular pain in the leg can be
  caused by either a lumbar condition or by a
  sacroiliac joint condition.
• The following tests help to differentiate between
  the two sources of pain.

98
Sacroiliac Joint Syndrome

• Clinical Signs and Symptoms
• Lower back pain
• Sacroiliac joint pain
• Aggravated by sitting
• Alleviated by standing or walking
• Lower extremity radicular pain

99
Goldthwaiths Test

• Procedure Patient supine. Place one hand under
  the lumbar spine with each finger under an
  interspinous space. With the other hand perform
  a straight leg raising test.
• Positive Test Radicular pain before the fanning
  out of the lumbar vertebra indicates an
  extradural lesion such as a sacroiliac joint
  lesion. Radicular pain during lumbar fanning
  indicates an intradural lesion such as a
  space-occupying lesion. Local pain after lumbar
  fanning indicates a posterior lumbar joint
  disorder.

100
Goldthwaiths Test
101
Nachlas Test

• Procedure Patient prone. Approximate the
  patients heel to the buttock on the same side.
• Positive Test Stretches the femoral nerve
  (largest branch of the lumbar plexus). Radicular
  pain to the anterior thigh compression or
  irritation of the L2 L4 nerve roots by an
  intradural lesion. Pain in the buttock SI
  joint lesion. Pain in the lumbosacral joint
  lumbosacral lesion.

102
Nachlas Test