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Ageing and degenerative changes of the intervertebral disc and their impact on spinal
flexibility. Eur Spine J 2014;23(3 suppl 3):S324-S332.
This literature review suggests that the mechanical behavior of the lumbar spine is
altered by degenerative changes.
features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol
2015;36(4):811-816.
The authors review the many publications documenting that degenerative changes in the
spine are commonly seen in imaging studies of asymptomatic individuals.
changing view of disc degeneration. Spine J 2009;9(1):47-59.
associations in disc degeneration? The influence of phenotypes, age, population size,
and inclusion sequence in 809 patients. Spine (Phila Pa 1976) 2016;41(21):1649-1660.
The authors document how the apparent association between genetics and disk
degeneration is influenced by many factors. Level of evidence: IV.
2003;13(4):371-379.
significance. Seminars in Spine Surgery 2005;17(4):240-242.
spondylolisthesis: Analysis using magnetic resonance imaging and flexion/extension
films. Spine J 2014;14(9):1965-1969.
Instability is more likely when fluid is observed in the facet joint on MRI examination
of the lumbar spine. Fluid in the space between spinous processes is also associated
with instability.
Defining the inherent stability of degenerative spondylolisthesis: A systematic review. J
Neurosurg Spine 2015;23(2):178-189.
Multiple imaging-based observations can be identified that help predict stability at a
lumbar intervertebral level with degenerative spondylolisthesis.
been measuring instability properly? Spine (Phila Pa 1976) 1990;15(6):571-576.
facet joint fluid on MRI and dynamic instability be a predictor of improvement in back
pain following lumbar fusion for degenerative spondylolisthesis? Eur Spine J
2016;25(8):2408-2415.
MRI showed that the probability of finding excessive intervertebral translation between
flexion and extension increases with the thickness of fluid in the facet joint. Fluid in the
facet joint may help predict the likelihood of achieving good outcomes after spinal
fusion.
Spine (Phila Pa 1976) 2008;33(10):E311-E316.
dependent spinal stenosis and degenerative spondylolisthesis. Spine J 2007;7(2):245-
248.
the diagnosis of mobile and nonmobile L4–L5 degenerative spondylolisthesis. Spine J
2015;15(9):1956-1962.
The authors differentiate between static and dynamic spondylolisthesis.
Spondylolisthesis is classified as dynamic when there is a substantial change in listhesis
between supine and standing positions. Fluid in the facet joint is a clinical marker for
dynamic spondylolisthesis.
alters lumbar spine segmental stiffness in all modes of loading under a compressive
follower load. Spine J 2013;13(9):1134-1147.
The effect of degenerative changes on the biomechanics of an FSU are complicated but
have been documented using laboratory testing of cadaver spines. The results of these
laboratory studies can be helpful in further modeling and development of clinical
diagnostics.
mobility analyzed by kinetic magnetic resonance imaging. Spine (Phila Pa 1976)
2015;40(5):316-322.
MRI analyses of intervertebral motion of the lumbar spine in flexion and extension was
used to document the development of instability in patients with mild to moderate disk
degeneration and restabilization in those with severe degenerative disk changes. It
should be appreciated that substantial variability exists—not all moderately degenerated
disks are unstable and not all severely degenerated disks are stable.
translation in the lumbar spine. J Orthop Res 2015;33(4):450-457.
Based on laboratory testing of cadaver spines, increasingly severe disk degeneration
was not clearly associated with the amount of intervertebral shear translation when
spines were tested with a superimposed compressive load.
flexibility of the thoracolumbar spine. Spine (Phila Pa 1976) 2004;29(9):988-993.
of the disc, the facet joint, the muscle, and the ligament pathology by using kinetic
magnetic resonance imaging. Spine (Phila Pa 1976) 2009;34(23):2537-2544.
and facet joint degeneration. Eur Spine J 2006;15(6):705-718.
in patients with degenerative spondylolisthesis. Eur Spine J 2011;20(5):713-719.
The authors of this study reported a significant association between the sagittal plan
orientation of the pelvis, the body mass index of the patient, sagittally oriented facet
joints, and the presence of spondylolisthesis.
and tropism in the development of lumbar degenerative spondylolisthesis: An
international, large-scale multicenter study by the AOSpine Asia Pacific Research
Collaboration Consortium. Global Spine J 2016;6(5):414-421.
Based on a large sample, good evidence was found that degenerative spondylolisthesis
is more likely to occur in individuals with sagittally oriented facet joints. A threshold
level of 58° was identified as predictive of degenerative spondylolisthesis.
role of ethnicity on variation of lumbar facet joint orientation and the occurrence of
degenerative spondylolisthesis in Asia Pacific: A study from the AOSpine Asia Pacific
Research Collaboration Consortium. Global Spine J 2016;6(1):35-45.
This multinational, multiethnic study found that that ethnicity may not play a role in
facet joint orientation in most patients with degenerative spondylolisthesis in the AsiaPacific region.
resonance imaging correlate with radiographic instability in patients with degenerative
lumbar disease? Spine (Phila Pa 1976) 2007;32(14):1555-1560.
signal on magnetic resonance imaging in lumbar facets in relationship to degenerative
spondylolisthesis. Spine (Phila Pa 1976) 2007;32(17):1883-1887.
sign of degenerative spondylolisthesis. Radiology 1982;144(3):562.
cross-sectional area on magnetic resonance imaging in relationship to cervical
degenerative spondylolisthesis. Spine J 2013;13(8):856-861.
Spondylolisthesis in the cervical spine was much more likely to be detected from a
weight-bearing radiograph than a supine magnetic resonance image. The size of the
facet joints and left-right asymmetry of the facet joints was more likely to be found
when spondylolisthesis was observed.
orientation and the severity of cervical spondylolisthesis. Spine J 2016;16(1):10-15.
Asymmetry in the orientation of the left and right cervical facet joints is common.
Although the magnitude of spondylolisthesis is not associated with this asymmetry,
development of spondylolisthesis is more likely when asymmetry is present.
degenerative cervical spondylolisthesis in the symptomatic adult. Spine (Phila Pa 1976)
2013;38(17):E1115-E1120.
Spondylolisthesis of 2 mm or more was found in 20% of symptomatic patients, most
commonly at C4-C5 and C5-C6. Translational motion was greater and spinal canal
diameter smaller when spondylolisthesis was observed.
with morphological parameters on magnetic resonance images. Eur Spine J
2015;24(10):2236-2243.
This retrospective review of 117 patients with lumbar spinal stenosis reported that
evaluation of integral morphologic parameters was more important than evaluation of
individual morphologic parameters in these patients.
assessment of degenerative lumbar spinal stenosis: Is MRI superior to CT? Eur Spine J
2017;26(2):362-367.
Based on imaging studies of 54 patients who underwent both a CT and an MRI
examination, observer agreement in the assessment of lumbar stenosis was better using
the MRI examination than the CT examination.
following decompression without fusion for degenerative grade I lumbar
spondylolisthesis. J Neurosurg Spine 2013;18(4):340-346.
Risk factors for instability after uninstrumented decompression included preexisting
spondylolisthesis, preoperative intervertebral disk height greater than 6.5 mm, and
sagittally oriented facet joints.
degenerative lumbar stenosis: Systematic review and current concepts. Neurosurg
Focus 2015;39(4):E9.
Based on a systematic review of studies reporting data for a total of 2,496 patients,
postoperative radiographic instability was reported in 5.5% of the patients. Instability
was more common in patients with preexisting spondylolisthesis. Minimally invasive
decompression may reduce postoperative instability.
2013;25(2):131-137.
The authors provide a good overview of spinal instability and the potential for
decompression surgery to create instability.
effect of graded minimal-invasive decompression procedures on lumbar spinal stability.
Arch Orthop Trauma Surg 2012;132(9):1233-1239.
Based on tests using cadaver spines, resection of regions of the cranial and caudal
laminae (as might be performed during posterior decompression), and detachment of
the supraspinous ligament resulted in substantial increases in intervertebral rotation
between flexion and extension.
stabilization affect segmental mobility? A biomechanical study. Arch Orthop Trauma
Surg 2010;130(2):285-292.
cortical screw-rod fixation versus pedicle screw-rod fixation with and without interbody
support. Spine (Phila Pa 1976) 2013;38(8):635-641.
Based on laboratory tests of cadaver spines, the reduction in intervertebral motion
achieved using rods connected to cortical screws was no different than that of rods
connected to conventional pedicles screws. This study also provides helpful data to
document that substantial intervertebral motion can remain immediately after
instrumented lumbar fusions.
of insertional torque during pedicle screwing using cortical bone trajectory technique.
Spine (Phila Pa 1976) 2014;39(4):E240-E245.
The torque required to implant a properly placed cortical screw was substantially higher
than the torque required to implant a conventional pedicle screw. Level of evidence: II.
strength among different sizes of pedicle screws using the cortical bone trajectory:
What is the ideal screw size for optimal fixation? Acta Neurochir (Wien)
2016;158(3):465-471.
Based on computer models, cortical screws with diameters larger than 5.5 mm, lengths
greater than 35 mm, and a greater proportion of the length within the vertebral body
have greater pull-out strength.
bone trajectory screw compared with standard trajectory pedicle screw. Spine (Phila Pa
1976) 2016;41(6):E335-E341.
The conventional pedicle insertion path was found to be more resistant to failure with
repetitive loading compared with a path using cortical screws. In addition, some unique
morphologies present challenges in using cortical bone screws.
contribution toward total cervical range of motion: A comparison of cervical disc
arthroplasty and fusion. Spine (Phila Pa 1976) 2011;36(25):E1593-E1599.
The authors report that anterior cervical diskectomy and fusion resulted in increased
segmental motion adjacent to the fusion level, whereas no change in adjacent level
motion occurred after cervical disk arthroplasty. The clinical importance is not
documented in this study, but concern exists that the increased motion adjacent to
fusion levels may accelerate adjacent level degeneration.
contribution toward total lumbar range of motion in disc replacement and fusions: A
comparison of operative and adjacent levels. Spine (Phila Pa 1976) 2009;34(23):2510-
2517.
outcomes in cervical disk replacement surgery. J Spinal Disord Tech 2015;28(3):106-
113.
Multiple factors explaining variability in clinical outcomes can be measured from
preoperative and postoperative radiographs of the cervical disk of patients treated with
disk arthroplasty. Clinical outcomes of cervical disk arthroplasty may be optimized by
careful attention to the preoperative condition of the disk space and careful sizing and
placement of the arthroplasty device.
lumbar disc arthroplasty on spine kinematics and facet joint loads in flexion and
extension: A finite element analysis. Eur Spine J 2012;21(5suppl 5):S663-S674.
Computer models were used to help understand how the placement of a lumbar disk
arthroplasty device can affect intervertebral motion and resultant forces on the facet
joints. Some implant positions can result in separation of the device from the vertebral
end plates during flexion or extension. The importance of correct placement of disk
arthroplasty devices is emphasized.
Section 2
Diagnostics in Spine Care
SECTION EDITOR:
Charles H. Cho, MD, MBA
Chapter 5
Physical Examination in Spine
Care
John P. Metzler, MD
Abstract
An appropriate physical examination preceded by a patient history should
lead to a differential diagnosis in patients with spinal pain or neurologic
symptoms. The physical examination is needed to determine the presence
and severity of neurologic impairment. Every initial examination should
establish the presence or absence of an upper or lower motor neuron lesion
by assessing gait, balance, strength, sensation, and reflexes. For the patient
with spinal pain, provocative testing of joints, neural tissue, and soft tissue
can aid in the localization of a pain generator.
Keywords: diagnostic subgroup; neural tension test; neurologic
symptoms; pain provocation; physical examination
Neither Dr. Metzler nor any immediate family member has received anything of
value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this chapter.
Introduction
After taking an appropriate history, the physician should have a differential
diagnosis and a firm grasp of the concerns, beliefs, and motives that led the
patient to seek consultation from a spine specialist. The physical examination
can help determine the presence of spinal and nonspinal structural pathology,
identify and localize neurologic impairment, and determine the source(s) of
pain. Imaging studies, laboratory tests, and other diagnostic studies may or
may not be indicated based on the examination findings. Patients may bring
imaging studies and/or reports requested by other physicians to the
examination and be primarily concerned with addressing the listed findings.
Degenerative changes, disk protrusions, and spinal stenosis can be present in
asymptomatic individuals.
1-3
An appropriately detailed history and physical
examination is an important tool for sorting out the clinical significance of
imaging findings. A patient’s history and physical examination findings,
along with imaging when appropriate, are necessary to guide the selection of
medications, therapy, injections, and surgery.
Every physical examination of a new patient should include some
components of inspection, palpation, range of motion, and neurologic
evaluation. Depending on the presenting symptoms, the differential
diagnosis, and the prior imaging findings and administered treatments, the
level of detail in various parts of the examination may vary. The nature of the
patient’s symptoms can give the examiner an idea of which parts of the
examination may require more emphasis. Table 1 outlines diagnostic
subgroups based on presenting symptoms that may be useful to consider
when performing a spinal physical examination.
Neurologic Symptoms
Bilateral Symptoms
In the patient with neurologic symptoms in the bilateral upper or lower
extremities, the examination should include tests for signs of myelopathy or
cauda equina compression. Patients with myelopathy may report numbness or
weakness in the bilateral upper and/or lower extremities and may have
impaired balance, gait, or coordination. Patients with further progression of
myelopathy may have symptoms of urinary urgency or incontinence.
Extradural compression of the spinal cord often produces concomitant reports
of pain in the distribution of a specific nerve root or roots. Pain is less
common in patients with intradural lesions. In those presenting with painless
weakness, intradural compression and other neurologic conditions that can
damage the spinal cord should be considered before ascribing degenerative
changes seen on imaging studies as the definitive cause of weakness.
Retrospective reviews of patients with amyotrophic lateral sclerosis have
shown a high incidence of spinal decompressive surgery performed for
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