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38 I Patient Evaluation and Spine Overview
Figure 1–24 (A) A figure demonstrating the transperitoneal approach to the lumbar spine.
(B) The vertical incision splits the rectus abdominis in the midline linea alba. (From An HS, Riley L.
An Atlas of Surgery of the Spine. London, England: Martin Dunitz; 1998 [illustrator: Carole Russell
Hilmer]. Reprinted with permission.)
A
B
Chapter 1 Anatomy and Surgical Approaches 39
A
B
Figure 1–25 (A) The overlying peritoneum is incised with care being taken to avoid damaging the
underlying peritoneum. (B) The abdominal viscera are retracted and the underlying vertebral bod-
ies are exposed. (From An HS, Riley L. An Atlas of Surgery of the Spine. London, England: Martin
Dunitz; 1998 [illustrator: Carole Russell Hilmer]. Reprinted with permission.)
40 I Patient Evaluation and Spine Overview
Figure 1–26 (A) The omentum and peritored contest are reflected exposing he bifureation of the
zort a. (B) Retractors are placed along the common itiar arteries bilateral exposing the L5-S1 inter-
space.
A
B
Chapter 1 Anatomy and Surgical Approaches 41
Suggested Reading
An HS. Anatomy. Surgery of the Cervical Spine In: An HS, Simpson JM, eds. London: Martin Dunitz and
Williams and Wilkins; 1994
An HS. Surgical Approaches. Surgery of the Cervical Spine. In: An HS, Simpson JM, eds. London: Martin
Dunitz, and Williams and Wilkins; 1994
An HS. Surgical Exposure and Fusion Techniques of the Spine. Spinal Instrumentation. In: An HS, Cotler
JM, eds. Baltimore: Williams and Wilkins; 1992
An HS, Gordin R, Renner K. Anatomic considerations for plate-screw fixation of the cervical spine. Spine
1991;16:S548–S551
Bland JH, Boushey DR. Anatomy and physiology of the cervical spine. Semin Arthritis Rheum
1990;20:1–20
Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7:319–320
Bogduk N. The innervation of the lumbar spine. Spine 1983;8:286–293
Bogduk N, Tynan W, Wilson A. The nerve supply to the human intervertebral disks. J Anat
1981;132:39–56
Czervionke LF, Daniels DL. Cervical spine anatomy and pathologic processes. Applications of new MR
imaging techniques. Radiol Clin North Am 1988;26:921–947
Czervionke LF, Daniels DL, Ho PSP, et al. Cervical neural foramina: correlative anatomic and MR imaging
study. Neuroradiology 1988;169:753–759
Czervionke LF, Daniels DL, Ho PSP, et al. MR appearance of gray and white matter in the cervical spinal
cord. AJNR Am J Neuroradiol 1988;9:557–562
Daniels DL, Hyde JS, Kneeland JB, et al. The cervical nerves and foramina: local-coil MR imaging. AJNR
Am J Neuroradiol 1986;7:129–133
Daniels DL, Williams AL, Haughton VM. Computed tomography of the articulations and ligaments at the
occipito-atlantoaxial region. Radiology 1983;146:709–716
DeAndrade JR, Macnab I. Anterior occipitocervical fusion using an extra-pharyngeal exposure. J Bone
Joint Surg Am 1969;51A:1621–1626
Dommisse GF. The blood supply of the spinal cord. J. Bone Joint Surg Br 1974;56B:225–228
Ellis JH, Martell W, Lillie JH, Aisen AM. Magnetic resonance imaging of the normal craniovertebral junc-
tion. Spine 1991;16:105–111
Fang HSY, Ong GB. Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am
1962;44:1588–1593
McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with
incomplete neurological deficit using retroperitoneal approach. J Bone Joint Surg Am 1985;67A:89–96
Panjabi MM, Duranceau J, Goel V, Oxland T, Takata K. Cervical human vertebrae. Quantitative three-
dimensional anatomy of the middle and lower regions. Spine 1993;16:861–874
Pech P, Daniels DL, Williams AL, Haughton VM. The cervical neural foramina: correlation of microtomy
and CT anatomy. Radiology 1985;155:143–146
Phillips JH, Kling TF, Cohen MD. The radiographic anatomy of the thoracic pedicle. Spine
1994;19:446–449
Rauschning W. Anatomy and pathology of the cervical spine. In: Frymoyer JW, ed. The Adult
Spine.1991:907–929
Shinomiya K, Okawa A, Nakao K, et al. Morphology of C5 ventral nerve rootlets as part of dissociated
motor loss of deltoid muscle. Spine 1994;19:2501–2504
Turner PL, Webb JK. A surgical approach to the upper thoracic spine. J Bone Joint Surg Br
1987;69B:542–544
Watkins RG. Surgical approaches to the spine. New York: Springer-Verlag; 1983
Whitesides TE Jr, Kelley RP. Lateral approach to the upper cervical spine for anterior fusion. South Med J
1966;59:879–883
Yu S, Sether L, Haughton VM. Facet joint menisci of the cervical spine: correlative MR imaging and
cryomicrotomy study. Radiology 1987;164:79–82
2
History and Physical
Examination
History
I. Degenerative disorders of the spine
A. History is the most important component of the patient evaluation.
1. Establishes the initial differential diagnoses
2. Guides physical examination and selective diagnostic tests
B. Spinal pain can be described as
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 and/or infections.
(1) Independent of activity
(2) Worse at night
(3) Not relieved by rest or immobilization
2. Axial versus radicular
a. Axial pain is usually diffuse.
(1) Referred pain to the scapula or shoulder in cervical spine
disorders
(2) Buttock or posterior thigh in lumbar 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)
42
◆
Figure 2–1 Motor examination for cervical and lumbar nerve roots.
Chapter 2 History and Physical Examination 43
44 I Patient Evaluation and Spine Overview
Figure 2–2 Myelopathic motor examination findings. (A) Finger escape sign. (B) Jaw-Jerk REflex .
A
B
Chapter 2 History and Physical Examination 45
C
Figure 2–2 (Continued ) Myelopathic motor examination findings. (C) Hoffman’s sign. (D) Babinski’s
sign. (from An HS. Principles and Techniques of Spine Surgery. Baltimore: Williams and Wilkins;
1998. Reprinted with permission.)
D
C. Myelopathy (Fig. 2–2)
1. Presents with poorly characterized pain
a. Vague sensory and motor symptoms over a long period of time are
also common.
2. Associated with neck, arm, or leg pain in a nondermatomal pattern or
with pain in a cervical dermatome
3. Slow and broad-based gait
4. Problems with upper extremity fine motor functions
a. Difficulty with fastening buttons is noted early.
b. Lower extremity dysfunction and spasticity
c. Bowel and bladder dysfunction noted later.
5. Associated with pathological long tract signs (Table 2–2)
46 I Patient Evaluation and Spine Overview
Table 2–1 Nerve Tension Signs
Cervical Tension Signs Findings
Spurling’s Neck extension and rotation toward the painful side causes
radicular limb pain.
Compression Axial loading on the head reproduces pain.
Distraction test Skull traction relieves pain.
Shoulder Abduction Elevation of painful limb relieves pain.
Lumbar Tension Signs Findings
Lasegue [Straight leg raise (SLR)] Elevation of painful limb causes radicular limb pain, not
back pain. Pain should be reproduced with less than
60 degrees of hip flexion.
Bowstring After reproducing the patient’s pain and obtaining a positive
Lasegue’s sign, the knee is flexed. This is positive if the
patient’s pain resolves with flexion of the knee.
Frajersztajn (Contralateral SLR) Elevation of the nonpainful limb cause back and limb pain
on the opposite side (usually means sequestered or
large extruded herniated disk).
Femoral stretch (Reverse SLR) Hip extension in either the lateral decubitus or prone
position stretches the femoral nerve and reproduces
pain in the L3 or L4 distribution.
II. Traumatic disorders
A. The ABC (airway, breathing, and circulation) should be checked first in
any trauma patient.
B. The mechanism of injury should be sought.
C. Pain and neurological symptoms should be documented.
III. Spinal deformity
A. Deformity and pain are the two most common presenting
complaints.
1. Pain is a more ominous sign in the child.
a. Possible etiologies include
(1) Spinal cord or bony tumor
(2) Scheuermann’s disease
(3) Spondylolisthesis
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. Medical history, family history, onset of menarche, time of curve detection,
and progression should be obtained in the adolescent scoliotic patient.
Chapter 2 History and Physical Examination 47
Physical Examination
I. Inspection
A. Look for obvious deformities in both the coronal and sagittal plane
1. Coronal plane
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
2. Sagittal balance and regional deformities
a. Normal cervical lordosis: 20 to 40 degrees
b. Normal thoracic kyphosis: 20 to 45 degrees
c. Normal lumbar lordosis: 40 to 60 degrees
B. Look for skin or subcutaneous lesions
Table 2–2 Myelopathic Signs
Long Tract Sign/Reflex Findings/Provocative Maneuver
Lhermitte’s Neck flexion causes electric shock sensation or paresthesias
radiating into the upper and lower extremities.
Finger escape Ask the patient to keep the fingers in full extension and the
ulnar digits tend to abduct.
Jaw jerk Hyperreflexia on tapping the jaw suggests an upper motor
neuron lesion at the level of the brain stem. Involves the
masseter and temporalis muscles and the fifth cranial nerve.
Shimizu (scapulohumeral) Tapping the tip of the spine of the scapula and the acromion
elicits elevation of the humerus. Reflex suggests spinal cord
compression at the upper cervical region.
Inverted radial Tapping of the brachioradialis tendon causes spastic finger
flexor contraction instead of normal extension of the wrist.
Positive reflex suggest spinal cord compression at the C6
region.
Hoffman’s Holding the middle finger extended and suddenly extending
the Distal Interphalarged Joint (DIP) will produce finger and
thumb flexion.
Babinski Gentle stimulus applied to the lateral aspect of the sole of the
foot starting over the heel extending toward the fifth digit. A
positive Babinski’s sign refers to the initial dorsiflexion of the
great toe upward and the spreading of the other toes.
Clonus Rhythmic, nonvoluntary movements of the muscle with firm
passive continuous stretch.
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