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position, with increased tension on the dura obtained by having the patient
flex the neck and thoracolumbar spine (ie, slumped position)21 (Figure 6).
Tension can be placed on the upper lumbar nerve roots (L2 through L4) via
the femoral nerve stretch test (Figure 7). With the patient prone, the
examiner flexes the patient’s knee as far as possible and then adds hip
extension, looking for reproduction of the patient’s typical radiating
symptoms of pain or paresthesias. If the patient is unable to lie prone, side
lying can be used as an alternative option.
The cervical nerve roots can be similarly tested with upper limb tension
tests21 (Figure 8). The C5 through C8 nerve roots can be strained and
displaced inferolaterally. To perform the test, the patient is supine and the
shoulder is depressed, abducted, and externally rotated; the elbow, wrist, and
fingers are extended.22 If the examiner wants to more selectively stress the
C7 nerve root or radial nerve, the patient’s shoulder is abducted and
internally rotated, the elbow is extended, the forearm is pronated, and the
wrist and fingers are flexed. Selective bias of the C8 root and ulnar nerve can
be achieved by abducting the shoulder to 90° and then bringing the patient’s
hand to his or her ear, thereby flexing the elbow, supinating the forearm, and
extending the wrist and fingers.21 Upper limb tension has been demonstrated
to have a high sensitivity but low specificity in making a diagnosis of cervical
radiculopathy.
23,24
Figure 6
Clinical photograph of the seated slump test. To maximize
tension on the L5 and S1 nerve roots, the seated patient is
asked to slump forward. The symptomatic lower extremity then is
extended and the ankle is dorsiflexed. Reproduction of the patient’s
typical pain or paresthesias is considered a positive test.
Figure 7
Figure 8
Clinical photograph of an examiner administering the femoral nerve
stretch test. The L2 through L4 nerve roots are stretched by
placing the patient prone and then flexing the knee and
extending the hip. Reproduction of the patient’s typical pain or
paresthesias is considered a positive test.
Clinical photographs of upper limb tension tests. Upper
extremity nerves are placed under tension and the patient is
asked if typical pain or paresthesias is reproduced. A, To create
median nerve bias, the patient is placed supine and the shoulder is
depressed, abducted, and externally rotated; the elbow, wrist, and
fingers are extended. B, Radial nerve bias is created by placing
increased tension on the radial nerve. The patient’s shoulder is
abducted and internally rotated, the elbow is extended, the forearm is
pronated, and the wrist and fingers are flexed. C, Ulnar nerve bias is
created to place increased tension on the ulnar nerve. The shoulder is
abducted to 90° and the patient’s hand is brought to his ear, thereby
flexing the elbow, supinating the forearm, and extending the wrist and
fingers.
Pain in the posterior pelvic girdle (defined as the area between the
posterior iliac crest and the gluteal fold or area around the sacroiliac [SI]
joint) can originate from outside the spine. Physical examination of this
region relies on using a constellation of findings to determine if the SI joint
and surrounding soft tissues are potential pain generators. Palpation just
inferior to the posterior superior iliac spine over the long dorsal ligament
frequently reveals tenderness. Tenderness to palpation may also be found at
the symphysis pubis. Difficulty in performing the active straight leg raise is a
common finding, and its presence suggests a lack of motor control that may
help perpetuate a chronic painful condition caused by repetitive mechanical
irritation of pain-sensitized structures.
25-27
Figure 9
Clinical photographs of a patient undergoing sacroiliac joint
provocation tests. Tests are consider positive if there is
reproduction of the patient’s typical pain. A, The distraction test. With
the patient supine, the examiner’s hands are placed on the anterior
superior iliac spine of each ilia and a lateral and posterior force is
applied. B, The thigh thrust test. With the patient supine and the hip
flexed to 90°, a posteriorly directed force is applied to the femur,
placing a shearing stress on the sacroiliac joint. C, The compression
test. The patient lies on the asymptomatic side and the examiner
places pressure on the superior iliac crest, directing it toward the
opposite iliac crest. D, The sacral thrust test. With the patient prone
and the ilia fixed against the examination table, the examiner’s hand is
placed in the center of the sacrum. An anteriorly directed force is then
applied.
No single isolated provocation test of the SI joint correlates well with a
diagnostic intra-articular or lateral branch block. All SI joint provocation tests
stress additional tissues outside the SI joint, which makes interpretation of a
single test difficult. However, when four provocative tests are applied
(distraction, thigh thrust, compression, and sacral thrust) and two or more
tests are positive for reproducing the patient’s typical symptoms, there is a
strong correlation with relief from a diagnostic SI joint block.
4,28
In addition,
when all four tests are negative, the SI joint can effectively be ruled out as the
source of the patient’s typical pain.
4,28
Figure 9 demonstrates the
provocation tests. The distraction test is performed with the patient supine.
With the examiner’s hands on the anterior superior iliac spine of each ilia, a
lateral and posterior force is applied. The thigh thrust or posterior shear test is
performed with the patient supine and the hip flexed to 90°. A posteriorly
directed force is then applied to the femur, placing a shearing stress on the SI
joint. To perform the compression test, the patient lies on the asymptomatic
side and the examiner places pressure on the superior iliac crest, directing it
toward the opposite iliac crest. The sacral thrust test is performed with the
patient prone and the ilia fixed against the examination table. The clinician’s
hands are placed one on top of the other in the center of the sacrum. An
anteriorly direct force is then applied, and the presence or absence of pain
provocation is noted.
29,30
The differential diagnosis for spinal pain and radiating pain is extensive
and extends to systems outside the spine. Initial suspicion of a nonspinal
etiology may occur when the patient’s history is being taken. Pain that is
modified by the state of the viscera (eg, pain after eating, with urination, with
exertion) should heighten awareness of a possible nonspinal pain generator.
In addition, associated systemic symptoms such as fever, nausea, or shortness
of breath should lead to examination of associated systems.
Summary
A multitude of techniques exist for spinal examination. By paying close
attention to a patient’s history, the clinician can select an appropriate
examination that will detect and localize neurologic impairment and
determine pain generators. By spending an appropriate amount of time and
thoughtfully performing the physical examination, an appropriate diagnostic
modality or treatment can be determined.
Key Study Points
Depending on the patient’s symptoms, the physical examination may be
varied to help further differentiate a diagnosis and determine specific
treatments.
An appropriately detailed neurologic examination is necessary to diagnose
urgent and emergent spinal conditions, localize spinal pathology, and
detect other neurologic disorders.
Observation, palpation, and provocative testing can assist in the detection
of spinal pain generators and nonspinal pain generators that mimic spinal
conditions.
The physical examination can help guide the selection of appropriate
imaging and treatment options.
Annotated References
1. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW: Abnormal magneticresonance scans of the lumbar spine in asymptomatic subjects: A prospective
investigation. J Bone Joint Surg Am 1990;72(3):403-408.
2. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S: Abnormal
magnetic-resonance scans of the cervical spine in asymptomatic subjects: A prospective
investigation. J Bone Joint Surg Am 1990;72(8):1178-1184.
3. Wood KB, Garvey TA, Gundry C, Heithoff KB: Magnetic resonance imaging of the
thoracic spine: Evaluation of asymptomatic individuals. J Bone Joint Surg Am
1995;77(11):1631-1638.
4. Kraemer M, Buerger M, Berlit P: Diagnostic problems and delay of diagnosis in
amyotrophic lateral sclerosis. Clin Neurol Neurosurg 2010;112(2):103-105.
5. Srinivasan J, Scala S, Jones HR, Saleh F, Russell JA: Inappropriate surgeries resulting
from misdiagnosis of early amyotrophic lateral sclerosis. Muscle Nerve 2006;34(3):359-
360.
6. Nishimura H, Endo K, Suzuki H, Tanaka H, Shishido T, Yamamoto K: Gait analysis in
cervical spondylotic myelopathy. Asian Spine J 2015;9(3):321-326.
The authors of this study report on 98 patients with cervical spondylotic myelopathy
and 34 normal control patients who underwent gait analysis. The severity of the gait
abnormalities corresponded with the severity of Nurick grade.
7. Ahlskog JE; Mayo Foundation for Medical Education and Research: Clinical
Examinations in Neurology, ed 6. St. Louis, MO, Mosby, 1991, pp 247-248.
8. Hosono N, Sakaura H, Mukai Y, Kaito T, Makino T, Yoshikawa H: A simple
performance test for quantifying the severity of cervical myelopathy. J Bone Joint Surg
Br 2008;90(9):1210-1213.
9. Fraser S, Roberts L, Murphy E: Cauda equina syndrome: A literature review of its
definition and clinical presentation. Arch Phys Med Rehabil 2009;90(11):1964-1968.
of outcome in cauda equina syndrome. Eur Spine J 1999;8(4):317-322.
Clin N Am 2011;22(1):7-40.
Part of this review concerns lumbar and cervical radiculopathy. Extensive citations are
provided regarding the sensitivity and specificity of various physical examination
maneuvers used for patients with radiculopathy symptoms.
Rehabil 1994;73(5):338-340.
radicular pain in cervical extradural compressive monoradiculopathies. Spine (Phila Pa
1976) 1981;6(5):441-446.
with lumbar disc herniation: Its curve pattern and natural history after lumbar
discectomy. BMC Musculoskelet Disord 2011;12:216.
The authors report on 26 adolescents who presented with a lumbar disk herniation and
scoliosis. Most of the patients had a short lumbosacral curve and a long thoracic curve
and their bodies were shifted to the contralateral side of the disk herniation. All patients
showed improvement in their scoliosis after diskectomy.
Orthopaedic Surgeons, 2004, pp 11-21.
England, Mosby, 2002.
trial of exercise for low back pain. Spine (Phila Pa 1976) 2004;29(23):2593-2602.
clinical dichotomies: Acute versus chronic pain and axial low back pain versus sciatica.
PMR 2012;4(9):667-681.
Data show that patients with low back pain and a directional preference respond well to
treatment that uses directional preference. The location and duration of pain and the
presence of neurologic impairment are not predictive of response.
root compression in cervical disc disease. Spine (Phila Pa 1976) 1989;14(3):253-257.
Livingstone, 1991.
during upper limb neural tension testing: Part 1. A minimally invasive assessment in
unembalmed cadavers. Spine (Phila Pa 1976) 2015;40(11):793-800.
The cervical nerve roots in 11 cadavers were examined using radiolucent markers under
fluoroscopy. This is the first study to measure displacement and strain of the cervical
roots during the median biased upper limb neural tension test. Level of evidence: II.
of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical
radiculopathy. Eur Spine J 2007;16(3):307-319.
neck and low-back pain. Best Pract Res Clin Rheumatol 2008;22(3):471-482.
leg raise in chronic pelvic girdle pain subjects. Spine (Phila Pa 1976) 2009;34(9):861-
870.
the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17(6):794-819.
(ASLR): An electromyographic study in healthy subjects. Man Ther 2012;17(6):531-
537.
The authors describe normal muscle activation patterns in healthy individuals
performing the active straight leg raise test with and without an SI belt. A lack of force
closure is proposed as a cause of an impaired active straight leg raise test.
Validity of individual provocation tests and composites of tests. Man Ther
2005;10(3):207-218.
joint pathology. Spine (Phila Pa 1976) 1994;19(11):1243-1249.
England, Elsevier Health Sciences, 2003, pp 950-951.
Chapter 6
Spine Imaging
Charles H. Cho, MD, MBA Robert M. Kurtz, MD
Abstract
The primary modalities for imaging of the spine are standard radiography
followed by advanced imaging with CT, myelography, MRI, bone scanning,
and positron emission tomography. Intraoperative fluoroscopy and CT are
becoming common for image-guided procedures. The requesting clinical
team and the equipment user should understand the risks and benefits
involved for any imaging delivery, including the energy used (radiation,
magnetic force) and the introduced medication (iodinated contrast,
gadolinium contrast, radioactive isotope). Throughout this process,
familiarization with the national guidelines for the specific imaging study is
important for optimal patient care with value in care delivery.
Dr. Cho or an immediate family member serves as a board member, owner,
officer, or committee member of the North American Spine Society. Neither Dr.
Kurtz 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.
Keywords: guidelines in spine imaging; risks of spine imaging;
spine imaging modalities
Introduction
Of the five major imaging modalities (radiography, CT, MRI, nuclear
scintigraphy, and positron emission tomography [PET]), lumbar radiography
remains the starting point for imaging evaluation of individuals with spine
pain. Understanding spine imaging involves awareness of a few key
components, including familiarity with the basic strengths and weaknesses of
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