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44
1 Anatomy and Surgical Approaches
Fig . 1 . 3 2 ( a ) The ove rlyin g pe rit o ne u m is in c ise d ,
with care to avoid damaging the underlying peritoneum. (b) The abdominal viscera are retracted,
and the underlying vertebral bodies are exposed.
a
b
1 Anatomy an d Surgical Approaches 45
a
b
Fi g . 1 . 3 3 ( a ) The omentum and peritoneal contents are re ected, exposing the bifurcation of
the aorta. (b) Retractors are placed along the common iliac arteries bilaterally, exposing the L5–S1
int e rsp a ce .
46
1 Anatomy and Surgical Approaches
Sugg este d Reading
An HS. Anat om y. In: An HS, Simp son JM, ed s. Surger y of th e Cer vical Spin e. Lon d on , UK:
Mar t in Du n it z an d W illiam s an d Wilkin s; 1 994
An HS. Su r gica l a p p r oa ch e s . In : An HS, Si m p s o n JM , e d s. Su r ge r y o f t h e Ce r vi c a l Sp in e .
Lond on, UK: Mart in Du n it z an d W illiam s an d W ilkin s; 1994
An HS. Su r g ic al e x p o su r e a n d fu s io n t e ch n iq u e s o f t h e sp in e . In : An HS, Cot le r JM, e d s.
Spinal Inst r u m e n t ation . Balt im ore, MD: William s and Wilkin s; 199 2
An H S, Go rd in R, Re n n e r K. An a t o m ic co n s id e ra t io n s fo r p la t e - scr ew x a t io n o f t h e ce r v i-
cal sp in e. Spin e 1991;16 (10, Suppl):S548–S551
Bla n d JH , Bo u s h ey DR. An at om y a n d p h ys io lo gy o f t h e ce r v ic a l s p in e . Se m i n Ar t h r it is
Rh eu m 1 990;20(1):1–20
Fa n g H SY, On g GB. Di r e c t a n t e r io r a p p r o a ch t o t h e u p p e r c e r v ic a l sp in e . J Bo n e Jo in t Su r g
Am 1962;44:15 88– 1593
Lu belski D, Ab d u llah KG, Stein m et z MP, et al. Lateral ext racavit ar y, costotran sversectom y,
and transthoracic thoracotomy approaches to the thoracic spine: review of techniques
an d com p licat ion s. J Spinal Disord Tech 2013;26(4):222 –23 2
Phillip s JH, Kling TF Jr, Cohen MD. The ra d iogra p h ic an atom y of th e t h oracic pedicle. Spin e
1994;19(4):446–449
Watkin s RG. Sur gical App roach es to t he Spin e. New York, NY: Springer-Verlag; 1983
2 History and Physical Examination
2.1 History
I. Dege n e rat ive d is o r d er s o f t h e sp in e .
A. His t o r y is t h e m ost im p o r t an t co m po n en t o f t he p at ie n t evalu at io n .
1. Establishes the initial di erential diagnoses.
2. Guides physical examination and selective diagnostic tests.
B. Sp in al p a i n c a n b e d es c r ib e d a s m e ch a n ic a l ve rs u s n on m e ch a n ica l, o r a xia l
versu s radicu lar.
1. Mechanical versus nonmechanical.
a. Mechanical pain tends to be associated with activity.
(1) Relieved by rest.
(2) Progressively worse over the course of the day.
b. Nonmechanical pain is typically due to tumors or infections.
(1) Independent of activity.
(2) Worse at night.
(3) Not relieved by rest or imm obilization.
2. Axial versus radicular.
a. Axial pain is usually di use.
(1) Referred pain to the scapula or shoulder in cervical spine disorders.
(2) Referred pain to the buttock or posterior thigh in lum bar spine disorders.
b. Radicular pain is typically associated with paresthesia, numbness, or
weakness in a dermatomal distribution (Fig. 2.1).
(1) Associated with tension signs (Table 2.1).
C. Mye lo p at hy (Fig. 2.2):
1. Presents with poorly characterized pain.
a. Vague sensory and motor symptoms over a long period of time are also
com mon.
2. Associated with neck, arm, or leg pain in a nondermatomal pattern or with
pain in a cervical dermatome.
3. Characterized by a slow and broad-based gait.
4. Problems with upper-extremity ne motor functions.
a. Di culty with fastening buttons is noted early.
b. Lower-extremity dysfunction and spasticity.
c. Bowel and bladder dysfunction are noted later.
5. Associated with pathological long tract signs (Table 2.2).
II. Tr a u m at ic d isord e rs.
A. Th e a ir w a y, b re a t h in g, a n d cir cu lat io n (ABC) sh o u ld b e ch ecke d r st in a n y
trauma patient.
B. Th e m e ch a n i s m o f i n ju r y s h o u ld b e s o u gh t .
C. Pa in a n d n e u r o lo gica l s y m p t o m s s h o u ld b e d ocu m e n t e d .
47
48
2 History and Physical Exam inat ion
a
b
Fi g . 2 . 1 ( a , b ) Mo t or e xam in a t io n fo r ce rvical a nd lu m b a r n e rve ro o t s.
III. Sp in al d efo rm it y.
A. De for m it y a n d p ain a r e t h e t w o m o st co m m on p re se n t in g co m p la in t s .
1. Pain is a more ominous sign in the child.
a. There are several possible etiologies:
(1) Spinal cord or bony tum or.
(2) Scheuerm ann’s disease.
(3) Spondylolisthesis.
2 Histor y and Physical Exam inat ion 49
Ta b l e 2 . 1 Ne r ve t ensio n sig n s
Ce r v i c a l t e n s i o n s i g n s Fi n d i n g s
Spu rlin g ’s Ne ck e xt e nsio n a n d ro t at ion t owa rd t he p ain fu l sid e
causes radicular limb pain.
Co m p re ss io n Axia l lo ad in g o n t he h e a d re pro du ce s p a in .
Dist ract ion t e st Sku ll t ract ion relieve s p a in .
Sh o u ld e r a b du c t io n Ele vat ion o f p ain fu l lim b re lie ve s p ain .
Lu m b a r t e n s i o n s i g n s Fi n d i n g s
La s e g u e ’ s ( s t r a i g h t l e g
raise [SLR])
Bo w s t r in g Af t e r re p r o d u c in g t h e p a t ie n t ’s p a in a n d o b t a in in g
Fa j e r s z t a j n ’ s ( c o n t r a l a t e r a l S LR) El e v a t i o n o f t h e n o n p a i n f u l l i m b c a u s e s b a c k a n d
Fe m o r a l st r e t c h (r e ve r s e SLR) Hip e xt e n s io n in e it h e r t h e la t e r a l d e c u b it u s o r
Ele v a t io n o f p a in f u l li m b c a u s e s r a d i c u l a r l im b p a i n ,
not back pain. Pain should be reproduced with
< 6 0 ° o f h ip e xio n .
a positive Lasegue’s sign, the knee is exed. This is
positive if the patient’s pain resolves with exion of
the knee.
lim b pain o n t he o p po sit e sid e (u sua lly m ea n s
sequestered or large extruded herniated disk).
prone position stretches the femoral nerve and
reproduces pain in the L3 or L4 distribution.
2. In adults, pain associated with deformities tends to be present at the convexity.
a. Due to muscle fatigue early.
b. Localizes to the concavity when degenerative changes have occurred later.
B. M e d ica l h is t o r y, fa m ily h is t o r y, o n se t o f m e n a rc h e , t im e o f c u r v e d e t e ct io n , a n d
progression should be obtained in the adolescent scoliotic patient.
2.2 Physical Examination
I. In sp ect io n .
A. Lo o k fo r o bvio u s d efo r m it ies in b ot h t h e co ro n al a n d t h e sagit t a l p la n e .
1. Coronal plane (Fig. 2.3).
a. Scoliosis evaluated by a plumb line dropped from the seventh cervical
vertebra.
b. Pelvic obliquity.
c. Shoulder imbalance.
d. Scapular protuberance.
e. Rib prominence.
50
2 History and Physical Exam inat ion
b
a
c
d
Fi g . 2 . 2 Mye lo p a t hic m ot or e xam in a t ion n d ing s. (a) Finger escape sign. (b) Jaw-jerk re ex. Myelo-
pathic motor examination ndings. (c) Ho m an’s sign. (d) Babinski’s sign.
2. Sagittal balance and regional deformities.
a. Norm al ce r vical lordosis: 20 t o 40°.
b. Norm al t h oracic k yp h osis: 20 to 45°.
c. Norm al lum bar lordosis: 40 to 60°.
B. Lo o k fo r sk in o r s u b cu t a n e ou s le s i o n s.
1. Café au lait spots in neuro bromatosis patients.
2. Midline tufts of hair, dimples, or rosy spots may indicate occult spinal
dysraphism.
C. M u scle a t r op hy sh ou ld b e o b s e r ve d in n e u ro lo gic a lly im p air e d p at ie n t s .
II. Pa lp at io n .
A. Bo n y p a lp at io n .
1. Spinous processes.
2. Posterior superior iliac spines: “dimples”.
3. Scapula and ribs.
4. Iliac crests.
5. Sacrum and coccyx.
6. Trochanter and ischial tuberosity.
B. So ft t iss u e p a l p at io n fo r sp a s m o r t r ig g e r p oin t t en d er n ess .
1. Trapezius muscle.
2. Rhomboid/levator muscles.
2 Histor y and Physical Exam inat ion 51
Ta b l e 2 . 2 Mye lo p a t hic sig ns
Lo n g t r a c t s i g n / r e e x Fi n d i n g s / p r o v o c a t i v e m a n e u v e r
Lh e r m i t t e ’ s g r i p r e l e a s e Neck exio n ca u se s e le ct ric sh ock se n satio n o r p a rest he sias
radiating into the upper and lower extremities. Patient
has trouble making a st and fully extending ngers
repeatedly—normal 20 times in 10 seconds.
Fin g e r e sca p e Ask t h e p a t ie n t t o ke e p t h e n g e r s in fu ll e xt e n s io n a n d
the ulnar digits tend to gradually ex and abduct.
Ja w j e r k Hype rre e xia o n t a p ping t h e jaw suggest s an u p p er m ot o r
neuron lesion at the level of the brain stem; involves the
masseter and temporalis muscles and the fth cranial nerve.
Sh im izu
(scapulohum eral)
Ta p p i n g t h e t i p o f t h e s p i n e o f t h e s c a p u l a a n d t h e
acromion elicits elevation of the humerus. Re ex suggests
spinal cord com pression at the upper cervical region.
In ve r t e d ra d ia l Ta p p i n g o f t h e b r a c h i o r a d i a l i s t e n d o n c a u s e s s p a s t i c n g e r
exor contraction instead of normal extension of the wrist.
Posit ive re e x su gge st s sp in a l co rd co m pre ssio n at t he C6
region.
Ho man’s Holding t h e m iddle nge r e xt e nded a n d sudd e nly
extending the distal interphalangeal joint (DIP) will
produce nger and thumb exion.
Ba b in s ki’s Ge n t le s t im u lu s a p p lie d t o t h e la t e r a l a s p e c t o f t h e s o l e
of the foot starting over the heel extending toward the
fth digit. A positive Babinski’s sign refers to the initial
dorsi exion of the great toe upward and the spreading of
the other toes.
Clo n u s Rhyt hm ic, n onvo lun t a r y m o ve m en t s o f t he m uscle wit h
rm passive continuous stretch
3. Paravertebral muscles.
4. Gluteus muscles.
5. Piriformis muscle.
6. Sciatic nerve.
III. Ran ge o f m ot ion .
A. Ce r vica l sp in e.
1. Flexion: 45° (t h e ch in tou ch es t h e chest).
2. Ext en sion: 75 °.
3. Lat eral ben din g: 40 °.
4. Rotat ion : 75°.
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2 History and Physical Exam inat ion
Fi g . 2 . 3 Pelvic o b liquit y, sho u ld e r im ba lance, scap u la r p rot ub e ra n ce, a n d rib p rom ine nce in t h e coronal plane in a scoliosis patient.
B. Th o r a co lu m b a r sp in e .
1. Flexion: 80° (m easure t h e dist an ce from t h e t ip of hands t o the oor).
2. Ext en sion: 40°.
3. Lat eral ben din g: 40 °.
4. Rotat ion : 45°.
IV. Neurological exam in at ion of in d ividu a l roots.
A. Se n so r y t e st s.
1. Four distinct sensations with de ned anatomical pathways in the spinal cord:
a. Pain perception may be tested with de ned anatomical pathways of the
spinal cord.
2 Histor y and Physical Exam inat ion 53
b. Light touch may be tested with a cotton swab.
c. Temperature may be tested with two test tubes containing either a hot or
a cold solution.
d. Proprioception begins distally at the distal phalanx or great toe and
proceeds proximally to each larger joint.
2. The aim of sensory testing is to identify whether there is a dermatomal
pattern of sensory dysfunction, which would suggest spinal root pathology,
or a possible glove/stocking distribution that would suggest a neuropathy
(Table 2.3) (Fig. 2.4).
B. Mo t o r t e s t s.
1. Muscle tone—resistance to passive range of motion.
a. Hypertonia may indicate an upper motor nerve lesion.
b. Hypotonia may indicate a lower motor nerve lesion.
2. Muscle strength.
a. Grade 5: normal.
b. Grade 4: weak against resistance.
c. Grade 3: motion against gravity.
d. Grade 2: motion with gravity eliminated.
Ta b l e 2 . 3 An a t o m y o f d e r m a t o m a l d is t r ib u t io n
Ne rve root De rmato mal distributio n
C5 Up pe r o u te r arm
C6 Thu m b
C7 Lo n g n g e r
C8 Li t t l e n g e r
T1 Me d ia l fo re arm
T4 Nip p le
T1 0 Um b ilic u s
L1 G r o i n
L2 A n t e r i o r t h i g h
L3 K n e e
L4 M e d i a l m a l l e o l u s
L5 G r e a t t o e
S1 Sm all t oe
S2 Po st e rior t h ig h
S3– S5 An a l
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