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Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 193
that can help narrow the dierential diagnosis, and dene
further issues that may need to be addressed through additional testing. Although a thorough discussion is beyond the
scope of this chapter, appropriate portions of a general medical
examination need to be included in the assessment of a spinal
patient depending on the nature of the presenting issues.
Neurologic and orthopaedic examinations of varying degree
and complexity are also necessary. is chapter follows a more
focused approach to the examination of the spine with a discussion of basic neurologic assessment and relevant provocative maneuvers appropriate to a patient’s presenting problem.
Observation
e physical examination starts with observation, which
begins when the physician rst sees the patient. Movement
patterns, preferred postures, inconsistencies, and gait abnormalities should be noted by the clinician and sta members
throughout the patient’s visit. is observation needs to be
done casually during oce or facility interactions and during
the medical history, then in a more formal manner during the
examination. Formal observation should include an examination from the feet to the head. Trunk and appendicular alignment should be noted, paying particular attention to hip and
knee alignment. e spine should be assessed for alterations
from normal alignment or resting curvature, including scoliosis, kyphosis, alterations in lumbar or cervical lordosis, a
lumbar shi, and head and neck alignment with the trunk.
Symmetry of shoulder height and scapular positioning should
also be noted.
Gait assessment can be done aer initial observation,
looking specically for gait patterns suggestive of neurologic
decits, such as a steppage gait associated with footdrop or a
wide-based gait suggestive of proprioceptive, cerebellar, or
myelopathic pathology. Gait can be tested further by tandem
gait testing (heel-to-toe walking). Balance can be assessed by
simple observation and performing a single-leg stance with
various postural challenges (e.g., crouching on one leg). If a
patient has an antalgic gait (i.e., shortened stance phase of the
gait cycle), consideration should be given to a musculoskeletal
problem involving the hips, knees, or foot and ankle. Generally, patients with a lumbar radiculopathy do not exhibit an
antalgic gait pattern.
Spine range of motion (ROM) should be assessed for all
relevant spine segments. ere is debate as to what constitutes
“normal” range of spine motion and the signicance of any
perceived restriction of motion. In the lumbar spine, ROM has
been variably reported by using inclinometry, measuring the
distance from the ngertips to the oor, assessing segmental
motion, measuring dynamic motion, measuring motion with
the pelvis restrained, radiographic measurement, and using
variations of the Schober test (measuring the change in distance between a mark over the S1 spinous process and one
made 10 cm above this in standing that occurs between standing and exion).
e value of ROM measurements is questionable, however,
because some data do indicate that there is no consistent relationship between ROM and physical or functional impairment
82–85
in subjects with chronic low back pain.83 ROM generally seems
to decline with age, further complicating attempts at establishing normative data.82 Gross lumbar motions generally include
motion from the hips and lower extremities, and any lateral
exion or rotation involves coupled motion at multiple levels,
making it dicult to assess these reliably. It is important to
examine hip motion, however, because painful and restricted
hip motion, particularly in exion with internal rotation, that
mimics the patient’s usual pain would generally implicate the
hip as a source of pain.
Despite these substantial limitations, it is still important to
assess active spine motion in exion, extension, rotation, and
lateral exion. Along with absolute degrees of movement, the
examiner can assess symmetry of motion, preferred movement patterns, pain or symptom reproduction associated with
motion, the relative contributions of associated body segments
to motion (e.g., hips), motor control, and inconsistencies
between movement noted on formal examination and that
seen during casual observation or while the patient is otherwise distracted. Generally, patient motion should be assessed
actively within the patient’s range of comfort. ere is little or
no role for passive ROM because this adds little to the clinical
assessment and may place the patient at risk for further
38
injury.
For cervical and thoracic complaints, it is also important
to assess shoulder and scapular motion. Shoulder ROM can
be assessed actively by exion and abduction along with
passive motion of the glenohumeral joint. Scapular position
at rest and with various arm positions can reveal abnormal
movement patterns and may indicate problems with scapulothoracic function, other shoulder joint complex disorders, or
neurologic injury aecting the parascapular musculature (e.g.,
a long thoracic or spinal accessory nerve injury). Scapulothoracic dysfunction of various kinds may also be a source of pain
in patients with thoracic complaints.86 Reproduction of a
patient’s shoulder region pain by passive shoulder motion,
particularly if it is restricted, would generally implicate the
shoulder rather than the neck as the source of pain. Patients
with a cervical radiculopathy obtain relief with ipsilateral
shoulder abduction (the shoulder abduction relief maneuver);
patients with intrinsic shoulder pathology oen have repro-
duction of pain with shoulder abduction.
Observation should also include looking for atrophy,
edema, vasomotor changes, skin lesions, limb or joint deformity, contracture, and other signs that may have an impact on
a patient’s care.
Palpation
e relevant areas of the patient’s spine and related structures
should be palpated with the patient standing or, when appropriate, in side-lying or prone position. Palpation may aid in the
localization of the patient’s symptoms, the identication of an
injured structure, or the identication of associated so tissue
or bony abnormalities. It should be noted whether tenderness
is elicited in the midline or to either side of the midline,
potentially dierentiating between spinal pain and pain from
an adjacent so tissue source.38 Localized tenderness should
SECTION
II
194 DIAGNOSIS
be distinguished from diuse tenderness, the latter being less
consistent with a focal injury.
In the cervical spine, palpation should include the occipital
region; the anterior neck; the clavicular, supraclavicular, and
scapular regions; and the areas of the associated cervicothoracic musculature.38 In the thoracic region, palpation should
also extend across the posterior ribs to identify focal bony
tenderness that may suggest rib pathology rather than spine
pathology. Pain with palpation or percussion of the costovertebral angle may suggest renal pathology.87 Spondylolisthesis
can frequently be appreciated by a palpable step-o of the
spinous processes in the lumbar spine. In the lumbar region,
palpation should include not only the lumbar spine but also
the iliac crests, sacrum, sacroiliac joints, ischial tuberosities,
proximal hamstring, and greater trochanteric areas, as indicated, to assess for the possibility of contributing problems
from these regions. Trochanteric pain may mimic pain from
a spine etiology.
Clinicians need to recognize that the ability to accurately
identify a spinal level by palpation is quite limited. Multiple
studies have conrmed high rates of inaccuracy with manual
palpation, which raises concerns for the manual identication
of structural problems and for the precise placement of
medical instruments for spinal interventions.
88,89
Neurologic Examination
As with the general medical examination, the neurologic
examination may cover a wide range of factors, depending on
the particular presenting problem. e most common neurologic manifestations of spine pathology generally involve the
spinal nerve roots or the spinal cord, resulting in radicular or
myelopathic ndings on examination. e symptoms resulting from spine pathology may frequently overlap, however,
with symptoms of various peripheral nerve processes, central
nervous system disease, or anterior horn cell disease. An
examiner needs to be aware of the clinical presentations and
neurologic ndings associated with these disorders. A full
discussion of all relevant examination techniques and neurologic pathology is beyond the scope of this chapter, but can be
found in general neurology texts. is section focuses on
ndings more directly related to spine pathology.
A thorough understanding of dermatomal patterns is
essential for all clinicians examining spine patients. As a reference, the key sensory points identied by the American Spinal
Injury Association90 can be helpful in assessing or screening
patients with spine pathology (see Fig. 12.5). So-touch and
pin-prick sensation can be assessed well in most patients; the
examiner should distinguish between a dermatomal distribution suggesting nerve root pathology, a stocking or stockingand-glove distribution suggesting peripheral polyneuropathy,
multiple nerve distribution suggesting alternative peripheral
nerve pathology, or a nonorganic distribution. Proprioception,
vibration, position sense, and temperature sensation may also
be tested, particularly when there is concern for a spinal cord
or central nervous system process or a peripheral neuropathy.
Motor examination consists of several parts, including
strength, tone, coordination, muscle bulk, and involuntary
movements.87 Strength is the modality most generally assessed
by clinicians, but all portions of the motor examination may
be important in some patients with spine disorders. Involuntary movements may be noted in patients with cervical dystonia or in various neurologic diseases that may aect function,
such as Parkinson disease. e presence or absence of focal
muscle atrophy should be noted in all patients. e mere presence of focal atrophy implies neurologic injury or disease, and
the distribution of atrophic muscles can be helpful in dening
the type of pathology present. Fasciculations associated with
atrophic muscles imply the presence of lower motor neuron
injury. Muscle tone can be aected by many neurologic processes. Reduced tone suggests lower motor neuron involvement, whereas increased tone or spasticity is seen with upper
motor neuron disease. Coordination may be disrupted by
numerous pathways, generally involving the cerebellum or its
pathways, but weakness, proprioceptive loss, and cognitive
disturbance may also aect motor performance on tests of
coordination. Clinical methods to assess coordination include
rapid alternating hand and foot movements and nger-tonose testing.
87
Strength testing is generally done isometrically, but sometimes weakness can be better appreciated through dynamic or
repetitive movements that address endurance (e.g., multiple
single-leg toe raises to assess plantar exor strength). It is
essential to be aware of key muscle groups by myotome and
the peripheral nerve origin of those muscles. Important
muscle groups and motions associated with cervical and
lumbar myotomes are as follows:
C5—elbow exors, shoulder abductors and external rotators
C6—elbow exors, wrist extensors and pronators, shoulder
external rotators
C7—elbow extensors, wrist pronators
C8—extension of index nger, nger abduction and exion,
abduction of thumb
T1—nger abduction
L2—hip exion
L3—hip exion, hip adduction, knee extension
L4—knee extension, ankle dorsiexion
L5—ankle dorsiexion, great toe extension, ankle eversion,
hip abduction and internal rotation
S1—ankle plantar exion, toe exion
Strength is generally graded on a scale of 0 to 5 as follows:
87
5—active movement against full resistance (normal strength)
4—active movement against gravity and some resistance
3—active movement against gravity
2—active movement with gravity eliminated
1—trace movement or barely detectable contraction
0—no muscular contraction identied
Active movement is generally meant to imply joint motion
through the full available ROM. For some muscle groups,
patients can oen have signicant loss of strength that is not
detectable by providing manual resistance with the examiner’s
arms; thus, other test maneuvers may be necessary to identify
more subtle weakness. Examples of such maneuvers would be
having the patient do a partial squat or arise from sitting
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 195
without using the upper extremities to assess for weakness in
the knee extensors. e Beevor sign (in which the umbilicus
moves craniad during contraction of the abdominal muscles
with supine neck exion) indicates weakness of the lower
abdominal muscles.
26
Reex testing can further aid in the localization of neurologic injury and help distinguish upper motor neuron from
lower motor neuron disease. In lower motor neuron injuries,
deep tendon reexes of aected regions are generally reduced,
whereas they are brisk in upper motor neuron injuries. e
Babinski response to appropriate plantar stimulation, Homan
sign in the hand, and clonus all can indicate the presence of
upper motor neuron injury. As with other physical examination ndings, the sensitivity and specicity of these ndings are
limited for any particular condition. In a study assessing the
prevalence of physical examination ndings in cervical myelopathy treated surgically, it was noted that 21% of the patients had
no myelopathic ndings on examination. Of the ndings just
mentioned, the Homan sign was the most sensitive (59%),
whereas the Babinski response had very low sensitivity (13%)
but was highly specic.91 Various other reexes—including
abdominal, cremasteric, and palmomental—can also be used
as part of the neurologic examination when appropriate.
Although a neurologic injury oen manifests as either an
upper or a lower motor neuron lesion, it can also manifest
with a mixed pattern of upper and lower motor neuron features, as can be seen with amyotrophic lateral sclerosis. e
segmental distribution of commonly tested deep tendon
reexes is as follows87:
Biceps reex—C5, C6
Brachioradialis reex—C5, C6
Triceps reex—C6, C7
Patellar tendon reex—L2, L3, L4
Medial hamstring reex—L5, S1
Ankle jerk reex (Achilles tendon)—S1
For the most part, the sensitivity and specicity of isolated
tests for sensation, strength, and reexes are relatively limited
in the assessment of spine conditions, particularly when any
one single test is considered.
22,85,92
ere may be more utility
in combining a variety of ndings across multiple modalities,
especially when the ndings are consistently reproducible. e
degree of consistency between examination ndings, history,
imaging results, and self-reported levels of pain and disability
for aected patients should always be considered when clinical
decisions on care are made.
Special Tests and Provocative Maneuvers
In addition to the standard examination techniques described
earlier, various provocative maneuvers and other tests have
been used to aid in the diagnosis of patients with spine conditions. e sensitivity and specicity of many of these tests are
either unclear or suboptimal, but a working knowledge of
their applicability is useful in the diagnosis and management
of patients with spine conditions.
e Lhermitte sign, although more technically a symptom,
is the presence of an electric shock–type sensation radiating
into the limbs with cervical exion. Although rst described
in a patient with multiple sclerosis, this sign is associated with
various spinal cord lesions.
26,38
If elicited with neck exion,
this sign should raise concern for the presence of a cervical
cord lesion. If elicited with trunk exion, this may indicate a
thoracic cord lesion.
26
e Spurling maneuver is a test for cervical nerve root
compression or irritation. A positive test is elicited by extending, rotating, and laterally bending the head to one side with
reproduction of radicular pain into the aected ipsilateral
extremity.
26,38
One study comparing the Spurling maneuver
with the results of electrodiagnostic testing found that the
maneuver had poor sensitivity (30%) but good specicity
(93%) in the diagnosis of electrodiagnostically conrmed
cervical radiculopathy.
93
e Valsalva maneuver is performed by having a patient
hold his or her breath and bear down. A reproduction of the
patient’s radicular symptoms or spinal pain with this maneuver
is believed to indicate a space-occupying lesion, such as a disc
herniation, in the spinal canal.
26,38
Dural tension signs are frequently used to assess lumbar
spine pathology. Many dierent maneuvers have been
described. A supine straight-leg raise is performed by elevating
the leg with knee extended and assessing for the reproduction
of pain into the leg. e test is considered positive if pain
occurs between 30 degrees and 70 degrees of elevation because
no true change in tension on the nerve roots is believed to
occur outside of this range.
3,85
Variations on this test include
the Lasègue sign or Bragard sign, which involves raising the leg
to the point of symptom reproduction and then lowering the
leg slightly and dorsiexing the foot passively; a positive test
results in reproduction of the patient’s radiating leg pain.
3,94
Other variants include internally rotating the leg to increase
“dural tension,” raising the leg with knee exed and then
slowly extending the knee to the point of reproduction of leg
pain (also sometimes referred to as the Lasègue sign), and
either relieving pain by exing the already extended knee at
the point of symptom reproduction or eliciting pain by pressing on the popliteal fossa of the elevated leg with the knee
partially exed (both varyingly called the bow string sign).
3,85,92,94
Additional tests include the crossed straight-leg raise, in
which symptoms are reproduced in the symptomatic leg by
performing a supine straight-leg raise on the contralateral leg,
and the femoral nerve stretch test or reverse straight-leg raise,
in which the patient is prone and the knee is passively exed,
with a positive test reproducing pain into the anterior thigh.
A positive straight-leg raise test and its variations indicates
tension on the lower lumbar roots and upper sacral root (L4,
L5, and S1 nerve roots). A positive femoral nerve stretch test
is the equivalent tension sign for the upper lumbar (L2–L4)
nerve roots.
3,85,92
Numerous studies have looked at the sensitivity and
specicity of some of these maneuvers. As might be surmised
by the varying descriptions and terminology, there are some
diculties with consistency in the literature. Overall, the
ipsilateral straight-leg raise test has a good sensitivity of
72% to 97% but a poorer specicity of 11% to 66%.92 e
crossed straight-leg raise test is less sensitive (23–42%) but
SECTION
II
196 DIAGNOSIS
more specic (85–100%) than the ipsilateral straight-leg
85,92
raise.
Tests proposed for assessing the sacroiliac joint include the
Gillet, Patrick, and Gaenslen tests. Although the sacroiliac joint
can be a source of pain, the diagnosis of “sacroiliac joint
dysfunction” is debated as a true pathologic entity. Dreyfuss
and colleagues28 studied numerous supposedly diagnostic
tests for this condition, including the Gillet, Patrick, and
Gaenslen tests, and compared the responses on these test
maneuvers with the results of uoroscopically guided sacro-
iliac joint blocks. ey found that no historical feature, none
of the diagnostic tests performed, and no combination of these
tests showed any signicant and reliable diagnostic value.
Nonorganic Signs
Chronic pain behavior is oen believed to display common
physical examination ndings suggesting symptom magnication and psychological distress, possibly an expression of
suering.
95,96
Waddell and colleagues95 dened and studied a
group of ve ndings on physical examination, commonly
known as Waddell signs. ese ndings consist of a supercial
or nonanatomic distribution of tenderness; a nonanatomic
motor or sensory impairment (regional disturbance); excessive verbalization of pain or gesturing (overreaction); production of pain complaints by tests that simulate only a specic
movement, such as low back pain that occurs with axial
loading on the crown of the head (simulation); and inconsistent reports of pain when the same movement is performed
in dierent positions, such as a straight-leg raise in a seated
versus supine position (distraction).
95
e presence of three or more of these signs indicates a
nonorganic component to an individual’s pain complaints.
e presence of Waddell signs does not mean, however, that
there is no signicant organic pathology present or that the
patient is malingering; objective clinical signs may be present
as well. Although some studies have found these maneuvers
to be reproducible, an evidence-based review by Fishbain and
colleagues97 noted that these ndings do not correlate with
psychological distress or secondary gain, and they do not
discriminate nonorganic from organic problems. ey are
associated with poorer treatment outcomes and higher pain
levels. Although these maneuvers may be useful, the clinician
should be wary of placing too much emphasis on any one part
of the physical examination.
Additional Orthopaedic Assessment
Depending on the area of the spine involved, it is frequently
important to cover additional areas of the orthopaedic
examination. As was previously mentioned, examination of
the shoulder complex is oen necessary in evaluating the
cervical and thoracic spine. Following the concept of the
kinetic chain, it is also oen helpful to assess multiple other
joint structures and movement patterns from the feet up
through the trunk to the neck, depending on the individual
patient’s situation.98 For the lumbar spine, examination of the
hip is also generally important, although examination of more
distal lower extremity structures and more cranial regions of
the spine and upper extremities may be necessary as well.
Because other conditions—such as carpal tunnel syndrome,
ulnar neuropathy, brachial plexopathy, peroneal neuropathy,
and femoral nerve injury (among others)—can masquerade
as radiculopathies, examination for these entities is also oen
indicated. As noted previously, an appropriate history can
help greatly in dening the scope of examination necessary
to evaluate a particular patient.
ere is a large body of literature on manual orthopae-
dic examination.
99,100
ese techniques generally are poorly
validated and of uncertain correlation to some of the more
“objective” ndings noted earlier. A systematic review of the
literature on the reliability of palpatory examination maneuvers found that most procedures have moderate or strong evidence for low reliability.
101
e authors noted that “a consistent
nding from work in this eld is the generally low reliability
of palpation-based assessment.”
101
ese techniques may be
helpful in certain treatment paradigms, however, and they
may be more useful when symptom response with repeated
movements is considered.
101
Another systematic review
assessed the literature on chiropractic tests of the lumbar spine
and found insucient evidence on the reliability and validity
of these tests to support their clinical role.
102
Risk Stratication
Distinct from the idea of the evaluation of an individual patient
is the concept of risk stratication within a population. Within
the clinical array of patients with spinal disorders, there are
clearly those who will require more extensive care and/or be at
risk for particularly poor outcomes. ere is increasing interest in applying screening mechanisms across a population to
help identify those patients with a poor prognosis for recovery
or in need of more intensive or multidisciplinary care. is
type of assessment may be incorporated into a patient’s initial
evaluation. An example of such a screening approach is the
STarT Back tool.
on prognostic factors for those with spinal pain, the STarT
Back questionnaire consists of nine questions addressing the
bothersomeness of pain, the presence of leg pain or concurrent neck symptoms, and the presence of fear avoidance or
other generally detrimental belief systems regarding pain.
e intent is to separate patients with more limited symptom
complexes and better coping skills who will likely do well
with standard treatments from those who may require more
advanced or complex interventions in order to improve
outcomes. In the primary study of the STarT Back tool, the
researchers developed and implemented a psychologically
driven physical therapy program for the more at-risk population, nding improvements in outcomes for those treated
based on risk stratication from those managed without any
such tool. ey also found that primary care providers did a
relatively poor job of appropriately identifying the physical
therapy needs of patients without using the questionnaire.
e broader applicability of this tool is currently under study,
but this type of work highlights the potential benets of stratifying patients for treatment. is may become an important
103
Consistent with the data noted earlier
104
103
Chapter 12 Patient History and Physical Examination: Cervical, Thoracic, and Lumbar 197
component of the medical history for patients with spinal
disorders.
Summary
e history and physical examination of a spine patient is a
complex undertaking. e nature of the patient’s presenting
complaints and relevant aspects of the history have a strong
bearing on the nature and extent of assessment required.
Clinicians caring for patients with spine disorders need to be
aware of all of the issues that may aect the presentation of a
patient and how these issues can aect the delivery of care. As
noted previously, it is of paramount importance to realize that
the person presenting with the spine problem is the primary
concern, and the spine problem is only secondary. Only by
speaking with and directly examining a patient can clinicians
truly understand the nature of the problem that they are being
asked to address.
KEY POINTS
1. A thorough and appropriate history and physical examination
are essential in the assessment of patients with spine disorders
to identify the physical manifestations of a spine disorder and
the root causes of the patient’s distress, suering, and disability.
2.
It is crucial to identify red ags and yellow ags in a patient’s
clinical presentation. Red ags are factors suggestive of the
presence of an urgent or emergent medical issue (e.g., infection,
tumor, fracture, cauda equina injury, progressive neurologic
loss). Yellow ags are factors associated with poor outcomes and
persisting pain and disability.
3.
The medical history can be used to narrow down the dierential
diagnosis and direct further diagnostic eorts through physical
examination and other tools.
4.
The value of isolated ndings on physical examination is limited,
although physical examination ndings become much more
signicant in the context of correlating history and imaging.
5.
Despite the importance of a thorough medical history, clinicians
need to realize that psychosocial factors are a more important
predictor of outcome in patients with spinal pain than
biomedical factors.
KEY REFERENCES
1. Bogduk N. The anatomy and pathophysiology of neck pain. Phys
Med Rehabil Clin N Am. 2003;14:455-472.
This is a concise overview of some important issues in assessing
patients with neck pain.
2.
Henschke N, Maher CG, Ostelo RWJG, et al. Red ags to screen
for malignancy in patients with low-back pain. Cochrane
Database Syst Rev. 2013;(2):CD008686.
An overview of the existing evidence on the use of red ags.
3.
Linton SJ. A review of psychosocial risk factors in back and neck
pain. Spine. 2000;25:1148-1156.
This is a useful and well-executed review of the role of psychosocial
risk factors in the development of chronic spinal pain.
4.
http://www.healthmeasures.net/explore-measurement-systems/
promis.
This is the website for the Patient-Reported Outcomes Measurement
Instrumentation System, a publically available set of outcome tools
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This is one of many useful chapters in a well-prepared text assessing
the literature on musculoskeletal physical examination.
6.
Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of Stratied
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2011;378:1560-1571.
Article on the STarT Back screening tool to assist in the treatment
stratication of patients with low back pain.
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SECTION
13
CHAPTER
Multiple imaging methods with tremendous technologic
complexity and sophistication can be used to evaluate spinal
pathology. Magnetic resonance imaging (MRI) quickly
emerged as the study of choice for many disorders of the
spine, with computed tomography (CT) continuing to play
a key role, bolstered by newer innovations such as helical
scanning and multidetector arrays allowing isotropic voxels
and multiplanar reformatting without loss of resolution. is
chapter reviews the basic imaging approaches to the spine
and their usefulness, both in specic disease states, and in
the context of the anatomic categories of spine pathology
(extradural, intradural extramedullary, and intramedullary).
Modalities
Radiographs
Routine plain lms are universally available and inexpensive,
but are limited by an inability to directly visualize neural
structures and nerve root or cord compression. Ionizing radiation is used to obtain the radiographic image, which despite
the relatively fast time of acquisition, can still be susceptible to
motion.1 Radiographs can be used for evaluation of alignment,
status of hardware in the postoperative patient, intraoperative
localization, and motion with exion-extension views.
Radiographs can visualize osseous structures and sur-
rounding so tissues (i.e., extradural pathology). A routine
examination of the spine includes frontal or anteroposterior
and lateral views, with additional views such as oblique or
exion-extension also available.
Orthogonal conventional radiography is the rst line of
evaluation in an instrumented postoperative patient, and
plain radiographs are usually obtained at 6 weeks and 3, 6,
and 12 months postoperatively.3 Regardless of which fusion
approach is taken, the presence or absence of demonstrable
motion or evidence of hardware failure or loosening is a
key factor in the evaluation. In the case of posterolateral
fusion, arthrodesis is deemed successful if follow-up radiographs show continuity in the fusion mass between the
cephalad and the caudal transverse processes. Instrumented
2
Spine Imaging
Todd M. Emch
Jerey S. Ross
Gordon R. Bell
interbody fusion is considered fused if any of the following is
present:
1. Increased or maintained bony density within the cage
implant because of the presence of mature bony trabeculae
bridging the interbody space
2. Absence of a halo or a periprosthetic lucency around the
implant
3. A sclerotic line between the cage and the vertebral bone
because of bone remodeling and new bone formation
4. Resorption of anterior vertebral traction spurs or the presence of bone gra anterior to an intervertebral implant
(sentinel sign)
5. Lack of motion on exion-extension views
Pseudarthrosis or failure of fusion is indicated by progres-
sive loss of disc height, vertebral displacement, broken or loose
hardware, and loss of position of the implant or resorption of
the bone gra. Flexion and extension views are useful for
assessing stability or functional fusion, but the central x-ray
beam should pass through the same area in both views.
Myelography
Myelography involves instillation of the contrast agent through
either lumbar puncture (midline or oblique approaches) or
lateral C1–C2 puncture with subsequent radiographic and CT
imaging of the region of interest. e diagnosis of extradural
neural compression by myelography is inferred indirectly by
changes in the contour of normal contrast agent–lled thecal sac
and root sleeves rather than by direct visualization of the lesion.5
Expansion of the spinal cord (Fig. 13.1) can be visualized as
well as intradural extramedullary lesions; however nonexpansile
cord pathology cannot be detected with myelography.
e major disadvantage of myelography is its invasive
nature and lack of diagnostic specicity.7 e use of less
toxic second-generation, water-soluble nonionic agents has
obviated the need for overnight hospitalization aer the
procedure. Routine postprocedural monitoring of 2 to 4
hours is usually sucient. Multiple water-soluble agents are
available that provide excellent contrast and lower rates of side
eects, such as iohexol (Omnipaque) and iopamidol (Isovue).
4
6
II
201
202 DIAGNOSIS
BC
A
FIG. 13.1 Computed tomographic myelogram demonstrating an intramedullary mass lesion. (A) Axial image
demonstrates normal diameter of the thoracic spinal cord. (B) Axial and (C) sagittal images demonstrate
fusiform expansion of the mid-thoracic spinal cord in this patient with an ependymoma.
Current water-soluble agents are associated with less toxicity,
and their absorption through the theca and arachnoid villi
makes their removal unnecessary.8 Newer nonionic watersoluble agents generally produce mild side eects, although
signicant adverse reactions can still rarely occur, such as
hallucinations, confusion, or seizures. Considerations before
myelography include obtaining screening laboratory tests
such as platelets, prothrombin time/international normalized
ratio, and partial thromboplastin time; medication history of
the patients, especially metformin; psychiatric medications,
which can lower seizure threshold; and anticoagulants.
9,10
Computed Tomography
CT permits direct visualization of potential neural compressing structures and provides better visualization of lateral
pathology, such as foraminal stenosis.
from a surgical perspective is the ability of CT to distinguish
neural compression due to so tissue from compression from
bone pathology.
12,14-16
Disadvantages of CT include radiation exposure, the eects
of partial volume averaging, streak artifacts in the cervical
spine caused by the dense bone of the shoulder girdle, and
changes in conguration of the spine that occur between
11-13
An important benet
successive motion segments.17 Many of the limitations can be
obviated by obtaining multiple thin sections (1.5 to 3 mm)
with the gantry tilted to permit imaging parallel to the plane
of the disc. Further accuracy is obtained by routinely imaging
the spine by CT aer the introduction of water-soluble contrast agents (intrathecal contrast medium–enhanced CT).
Reported accuracy rates for CT range from 72% to 91%.
7,12,14,15
Agreement rates between contrast medium–enhanced CT and
myelography have been reported to range from 75% to 96%.
12,14
When a discrepancy exists between myelographic and CT ndings, postcontrast CT is invariably the more accurate study (Fig.
13.2). Current multirow detector technology is now available
that allows for extremely rapid thin-slice acquisitions over long
body segments. With this technology, contiguous 3-mm slices
can be obtained from L1 to S1 in less than 30 seconds. e
acquisition of isotropic voxels allows for multiplanar reformation
of the CT data with no loss in spatial resolution. Changes in
the windowing and leveling of the images can change the focus
onto either osseous structures or so tissues.
1
Magnetic Resonance Imaging
MRI can readily evaluate the extradural, intradural extramedullary, and intramedullary spaces and is also the only modality