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54
2 History and Physical Exam inat ion
a
b
Fi g . 2 . 4 ( a , b ) Norm al d ist ribut io n o f d e rm a t om a l le ve ls.
e. Grade 1: evidence of contractility.
f. Gra d e 0 : n o evid e n ce of con t ract ilit y.
3. Motor root testing/re exes (Table 2.4).
V. S p e c i a l p r o v o c a t i v e t e s t s (Fig. 2.5).
A. Ad s o n ’s t e st .
1. Test to evaluate thoracic outlet syndrome.
2. Abduct, extend, and externally rotate the arm while feeling the radial pulse.
Als o r ot a t e t h e h e a d t ow a rd t h e t e st in g a r m .
a. If the pulse disappears with reproduction of symptoms, the test is positive.
B. Sa cr oilia c t es t s .
1. Patrick’s test: exion, abduction, and external rotation of the hip cause pain
referred from the sacroiliac joint.
2. Gaenslen’s test: dropping the leg on the table (extension of the hip) causes
pain in the ipsilateral sacroiliac joint.
2 Histor y and Physical Exam inat ion 55
Ta b l e 2 . 4 Mo t or st re ng t h t e s t in g
Ro o t M u s c l e s Re ex
C5 De lt oid , b ice ps Bice p s
C6 Bice p s, wris t e xt e nso rs Brach io ra dia lis
C7 Tr i c e p s , w r i s t e x i o n Tr i c e p s
C8 Fin g e r e xo r s
T1 , T2 Ha nd in t r in sics
T2 – T12 Int e rco st a ls ,
rectus abdominis
Be e v o r ’s sig n ( a b d o m in a l) —a s ym m e t r ic
contraction of the umbilicus with
stimulation of the abdomen
L1 – L3 I l i o p s o a s
L4 T i b i a l i s a n t e r i o r P a t e l l a r t e n d o n
L5 E x t e n s o r h a l l u c i s l o n g u s P o s t e r i o r t i b i a l t e n d o n
S1 Pero nea lis, g ast ro cn e m iu s Ach ille s
C. Bu lb oca ve r n o u s r e e x (Fig. 2.4):
1. Monitoring the anal sphincter contraction in response to squeezing the glans
penis or clitoris or pulling an indwelling Foley catheter.
D. Sch ober’s test .
1. Normal lumbar excursion is usually > 5 cm. Mark 10 cm from the posterior
superior iliac spine level when the patient is standing erect, and measure
the distance on forward exion. If it becomes < 15 cm, one should suspect
ankylosing spondylitis.
E. Wa d de ll’s s ig n s.
1. Nonorganic physical exam ndings.
2. If three or more signs are found, it is suggestive that the patient’s pain
complaints m ay not be anatom ical.
a. Nonanatomical or super cial tenderness that is not proportional to exam
ndings.
b. Simulated rotation or compression tests:
(1) Instruct the patient to stand with the feet together and rotate the
patient’s pelvis or press on the top of the head. These maneuvers
should not cause pain.
c. Extending the leg in the sitting position is negative but straight leg
raising in the supine position is m arkedly positive.
d. Weakness and sensory ndings that do not correspond to accepted
dermatomal distribution.
e. Verbal or physical overreaction to a particular maneuver.
56
2 History and Physical Exam inat ion
a
b
Fi g . 2 . 5 ( a ) Ad s o n ’s a n d t h e (b) modi ed Adson’s test to evaluate for thoracic outlet syndrome.
Sugg este d Reading
Al Ne za r i NH, Sch n e i d e r s AG, H e n d r ick PA. Ne u ro l o gi c a l e xa m in at io n of t h e p e r ip h e r a l
nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a system at ic review an d m eta- an alysis. Sp in e J 2013;13(6):657 –674
Cla r k CR. Ce r v ic al s p o n d y lo t ic m ye lo p at h y: h is t o r y a n d p h ys ic a l n d in gs . Sp in e 1 9 8 8 ; 1 3
(7):847–849
Iver se n T, So lb erg TK, Rom ner B, et al. Accu r a cy o f p h ysica l exa m in at io n fo r ch r o n ic lu m -
bar radicu lop athy. BMC Mu scu loskelet Disord 2 013 ;14:206
St an le y H o p pe n fe ld S. Ph ys ic a l e xa m in at io n o f t h e ce r v ica l s p in e a n d t e m p or o m an d i b u la r
joint. In: Physical Exam ination of the Spine and Extrem ities. Norwalk, CT: Appleton–
Cent u r y–Crofts; 19 76:105–132
3 Radiographic Anatomy
3.1 General Considerations
I. Th e ab ilit y to p r o p e r ly d iagn ose an d t re at sp in a l p at h o lo g y r e qu ir e s a t h or ou gh
understanding of the normal spinal anatomy.
II. Pat ie n t sym p t om s m u st co rrelat e w it h p os it ive im agin g n d in gs t o su rgically
address the speci c pathology.
III. On ce a d iagn osis is co n r m e d , t h e su rgeon m ust p la n t h e b e st su rgical t re at m e n t
option based on each patient’s individual anatomy.
IV. Plain lm radiograp h s are o ften t h e rst im agin g st u dy ob t ain ed for m ost sp in e -
related complaints.
A. La t e ra l view s a re u se fu l t o a sse s s sp in a l a lign m en t a n d in st a bilit y.
1. Cervical spine (Fig. 3.1).
2. Lumbar spine (Fig. 3.2).
B. Op e n - m o u t h v i e w : t o a ss e s s t h e d en s a n d a t la n t o a x ia l jo in t (Fig. 3.3).
Fi g . 3 . 1 La t e r a l p la i n l m r a d i o g r a p h o f (A) the
anterior border of the vertebral bodies, (B) the pos-
terior border of the vertebral bodies, and (C) the
jun ction of t h e lam in a e a nd sp ino u s p ro ce sse s.
57
58
3 Radiographic Anatomy
Fi g . 3 . 2 Lu m b a r s p i n e ( l a t e r a l p l a i n
lm radiograph in extension). 1, superior
articular process (SAP); 2, inferior articular proce ss (IAP); 3, sp in o u s p rocess; 4 ,
inte r ve rt eb ra l d isk space (n o e vid e n ce o f
anterior slip).
Fi g . 3 . 3 Ra d io g r a p h , o p e n - m o u t h
view. 1, dens; 2, at lant o a xial joint .
V. M a g n e t i c r e s o n a n c e i m a g i n g ( M R I ) i s p a r t i c u l a r l y u s e f u l t o a n a l y z e r e g i o n a l
anatomy and assess the safety and feasibility of surgery.
A. Ce r vic a l sp in e (Fig. 3.4).
B. Lu m b ar s p in e (Fig. 3.5).
VI. Com p u t e d t o m ogr a p hy (CT) c a n a lso b e u se d fo r p re op e r at ive p la n n in g (Fig. 3.6).
3 Radiographic Anatomy 59
Fi g . 3 . 4 Ma g ne t ic re so n an ce
im a g ing axial cu t at C4 d e m onst ra t ing no rm a l anat om y. 1 , t rachea; 2 ,
esophagus; 3, transverse process
(foram ina transversaria); 4, spinal
cord (note the high-intensit y signal
surrounding the spinal cord (cerebrospinal uid); 5, external carotid
artery; 6, internal carotid artery; 7,
int ernal jugular ve in; 8, fa ce t jo int
com plex; dot ted line, surgical plane
for ACDF.
Fi g . 3 . 5 Lu m b a r s p i n e ( m a g n e t i c
resonance imaging, T2—axial cut
L4 – L5 d i s k ) . 1 , l e f t c o m m o n i l ia c
artery (immediately after bifurcation of the abdominal aorta; 2,
inferio r ve n a ca va (p rio r t o bifu rcation of the left and right common
iliac ve ins; 3 , left p soas m uscle ;
4, spinal canal (cauda equina); 5,
face t joint ; MF, m ulti dus m uscle;
LS , l o n g i s s i m u s m u s c l e ; arrow,
inte rm uscular Wilt se plane (use d
in m inim ally in va sive ap p ro a ch es
and pedicle screw placement).
Fi g . 3 . 6 Lu m b a r s p i n e ( a x i a l c o m p u t e d t o m o g raphy at L3). P, pedicle; SP, spinous process; TP,
transverse process; dotted lines, trajectory for
spinal access needles and pedicle screws.
60
3 Radiographic Anatomy
3.2 Common Spinal Pathologies
I. Spo n d ylo sis: d e gen erat ive sp in al d is e a s e .
A. Fr e q u e n t r ad io gra p h ic n d in gs.
1. Loss of cervical lordosis.
2. Disk space narrowing (Fig. 3.7).
3. Osteophyte formations (Fig. 3.8).
a. Osteophytes can be observed in plain lm radiographs, but CT better
delineates the size and extent of osteophytic formation (important for
surgical planning).
Fi g . 3 . 7 La t e r a l p l a i n l m r a d i o g r a p h . 1 ,
normal disk height; 2, decreased disk height;
solid line, loss of cervical lordosis; dot ted
line , n o rm al ce rvica l lordosis.
Fi g . 3 . 8 Lu m b a r s p i n e ( s a g i t t a l c o m p u t e d
tomography). Notice osteophyte formation
anteriorly. L1, pedicle; L3, inferior articular
process (IAP); L4, superior articular process
(SAP); L5–S1, spondylosis.
B. MRI ch a n ge s .
1. Reduced disk signal on T2.
a. T2 is the preferred modality to characterize disk pathology. A normal disk
will demonstrate a high-intensity nucleus surrounded by a low-intensity
annulus.
(1) Loss of disk height and darkening of the intervertebral disk are
com m on MRI ndings in degenerative disk pathology (Fig. 3.9 and
Fi g . 3 .1 0 ).
3 Radiographic Anatomy 61
Fi g . 3 . 9 Sag it t a l m ag net ic resonance imaging cut of cervical
spine. 1, posterior arch of C1
(atlas); 2, spinal cord; 3, C5–C6
disk degeneration with posterior disk protrusion; C7, spinous
process.
Fi g . 3 . 1 0 Mag n et ic re so n an ce
im a g ing, a xial cut at C5–C6.
1, platysma muscle; 2, thyroid
gland; 3, common carotid artery;
4, internal jugular vein; 5, normal
exiting nerve root; 6, facet joint;
7, longus colli muscle; 8, deep
cervical m uscles; 9, trapezius; 10,
left he rniat e d nucle u s pulposu s
(HNP) causing foraminal stenosis.
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3 Radiographic Anatomy
2. Facet joint hypertrophy.
3. Intervertebral disk bulge or protrusion (herniated nucleus pulposus).
a. Central.
b. Paracentral.
c. Far lateral (Fig. 3.11 and Fig. 3.12).
Fi g . 3 . 1 1 Ma gn et ic re so n an ce
im ag in g axial cu t at L5– S1 . 1,
left co m m o n iliac vein; 2 , le ft
paracentral herniated nucleus
pulposus; 3, left L5 lamina; 4,
ilium .
Fi g . 3 . 1 2 Ma gn et ic re so na nce
im aging sagit tal cut t hro u g h t h e
spinous process. 1, end of spinal
cord (conus medullaris); 2, normal L3–L4 intervertebral disk
int ensit y; 3, L5– S1 d isk d e g e ne ration with posterior herniation.
3 Radiographic Anatomy 63
II. Ve r t eb ral b o dy colla p se.
A. Co m pr e ssio n fr a ct u r e s in o s t e op o r ot ic p a t ie n ts .
B. Pa t h olo gic a l fr a ct u re s fr o m t u m or s (m or e o ft e n m e t a st at ic ) .
C. Ch ar ac t e r iz e d b y l o ss o f v e r t eb ra l b od y h e igh t w it h o r w i t h ou t s e gm e n t al
kyphosis in lateral plain lm radiographs (Fig. 3.13 and Fig. 3.14).
D. CT is t he best im agin g st u dy for a ssessing bony an atom y.
Fig . 3 . 1 3 La t e r a l p l a i n l m r a d i o g r a p h . L1 b o d y
demonstrates decreased body height with local
kyphotic deformity.
Fi g . 3 . 1 4 Ma g n et ic re so na nce
im a g ing axial cut at t h e L1 b o d y.
1, bony defect consistent with
com pression fracture.
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