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48 I Patient Evaluation and Spine Overview
1. Café au lait spots in neurofibromatosis patients
2. Midline tufts of hair, dimples, or rosy spots may indicate occult spinal
dysraphism.
C. Muscle atrophy should be observed in neurologically impaired patients.
II. Palpation
A. Bony palpation
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. Soft tissue palpation for spasm or trigger point tenderness
1. Trapezius muscle
2. Rhomboid/levator muscles
3. Paravertebral muscles
4. Gluteus muscles
5. Piriformis muscle
6. Sciatic nerve
III. Range of motion
A. Cervical spine
1. Flexion: 45 degrees (the chin touches the chest)
2. Extension: 75 degrees
3. Lateral bending: 40 degrees
4. Rotation: 75 degrees
B. Thoracolumbar spine
1. Flexion: 80 degrees (measure the distance from the tip of hands to the
floor)
2. Extension: 40 degrees
3. Lateral bending: 40 degrees
4. Rotation: 45 degrees
IV. Neurological examination of individual roots
A. Sensory tests
1. Four distinct sensations with defined anatomic pathways in the spinal
cord
a. Pain perception may be tested with defined anatomic pathways in
the spinal cord.
b. Light touch may be tested with a cotton swab.
c. Temperature may be tested with two test tubes containing either a
hot or 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).
Chapter 2 History and Physical Examination 49
B. Motor tests (Fig. 2–3)
1. 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
e. Grade 1: evidence of contractility
f. Grade 0: no evidence of contractility
2. Motor root testing/reflexes (Table 2–4)
V. Special provocative tests
A. Adson’s test
1. Test to evaluate thoracic outlet syndrome
2. Abduct, extend, and externally rotate the arm, while feeling the radial
pulse. Also rotate the head toward the testing arm.
a. If the pulse disappears with reproduction of symptoms, the test is
positive.
B. Sacroiliac tests
(1) Patrick’s test: flexion, abduction, and external rotation of the
hip cause pain referred from the sacroiliac joint.
(2) Gaeslen’s test: dropping the leg on the table (extension of the
hip) causes pain in the ipsilateral sacroiliac joint.
Table 2–3 Anatomy of Dermatomal Distribution
Nerve Root Dermatomal Distribution
C5 Upper outer arm
C6 Thumb
C7 Long finger
C8 Little finger
T1 Medial forearm
T4 Nipple
T10 Umbilicus
L1 Groin
L2 Anterior thigh
L3 Knee
L4 Medial malleolus
L5 Great toe
S1 Small toe
S2 Posterior thigh
S3–S5 Anal
50 I Patient Evaluation and Spine Overview
Figure 2–3 Bulbocavernosus reflex is performed to determine the end of spinal shock.
Chapter 2 History and Physical Examination 51
C. Shober test
(1) Normal lumbar excursion is usually greater than 5 cm. Mark 10
cm from the posterior superior iliac spine level when standing
erect, and measure the distance on forward flexion. If it becomes
less than 15 cm, one should suspect ankylosing spondylitis.
D. Waddell’s sign
1. Nonorganic physical exam findings
2. If three of more signs are found, it is suggestive that the patient is
malingering.
a. Nonanatomic or superficial tenderness that is not proportional to
exam findings
b. Simulated rotation or compression tests
(1) Instruct the patient to stand with feet together and rotate the
pelvis or compress on the top of the head. These maneuvers
should not cause pain.
(2) Flip test
(3) Extending the leg in the sitting position is negative but straight
leg raising on supine position is markedly positive.
c. Nonanatomic weakness and sensory findings
d. Overreaction
Table 2–4 Motor Strength Testing
Root Muscles Reflex
C5 Deltoid, biceps Biceps
C6 Biceps, wrist extensors Brachioradialis
C7 Triceps, wrist flexion Triceps
C8 Finger flexors
T1, T2 Hand intrinsics
T2–T12 Intercostals, rectus abdominus Beevor’s sign (abdominal)–asymmetric
contraction of the umbilicus with
stimulation of the abdomen
L1–L3 Iliopsoas
L4 Tibialis anterior Patellar tendon
L5 Extensor hallucis longus Posterior tibial tendon
S1 Peroneals, gastrocnemius Achilles
Suggested Reading
Clark CR. Cervical spondylotic myelopathy: history and physical findings. Spine 1988;13:847-849
Stanley Hoppenfeld S. (Physical Examination of the Cervical Spine and Temporomandibular Joint). In:
Physical Examination of the Spine and Extremities. Norwalk, CT: Appleton–Century–Crofts; 1976
Waddell G, McCullough JA, Kummel E, Venner RM. Nonorganic physical signs in low–back pain. Spine
1980;5:117–125
3
Spinal Imaging and Diagnostic
Tests
Imaging Modalities
I. General considerations
A. Spinal imaging modalities (Table 3–1)
1. Plain radiographs
2. Computed tomography
3. Magnetic resonance imaging (MRI)
4. Bone scintigraphy
5. Myelography
6. Angiography
7. Discography
B. A thorough history and physical examination should lead to a preliminary
clinical diagnosis that should predicate both the selection and timing of
imaging tests.
1. Diagnostic tests should be used to confirm information ascertained
during the history and physical examination.
C. Selection of imaging tests should be based on the appreciation of the sen-
sitivity, specificity, and accuracy of various imaging modalities in con-
junction with different disease processes.
1. Acute neck or back pain and radiculopathy
a. Natural history is that of improvement with conservative treatment
b. Diagnostic imaging should be delayed until 4 to 6 weeks after the
onset of symptoms.
(1) Exceptions to earlier imaging evaluation include
(a) Trauma
(b) Progressive neurological deficit
(c) If neoplasm or infection suspected
2. Imaging evaluation alone without clinical correlation is associated
with an extremely high false-positive rate.
52
◆
Chapter 3 Spinal Imaging and Diagnostic Tests 53
Table 3–1 Imaging Modalities
Imaging Modality Indications/Advantages Limitations
Plain radiographs • Initial modality for trauma, • Not specific
neoplasm, infection, • Bone loss 30–40% needed
deformity, and degenerative to be detected by
disorders plain radiographs
Computed • Axial images with multiplanar • Less accurate in
tomography and three-dimensional demonstrating intrathecal
reconstruction capabilities and soft tissue pathology
• Advantages: bony detail, fractures, • Narrow field of view
differentiate hard/soft discs • Radiation exposure
Myelography • Water-soluble dye mixes • Invasive
and computed with the cerebrospinal fluid • Unable to assess distal
tomographic and outlines the dural sac to a complete block
myelography • Demonstrates an extradural • Computed tomography
mass by impression in the dye myelography improves
column or root cutoffs and the accuracy of foraminal/
intrathecal lesions by filling lateral recess stenosis and
defects herniated disc lesions.
Axial and reconstructed images
improve visualization of the lat-
eral recess and foramen
MRI • The procedure of choice for • Less bony detail as compared
the majority of spinal pathology with computed tomography
• Using pulsed RF, MRI detects the • Difficult to interpret in
energy released by a proton patients with a large
during the transition from and deformity
excited state to a baseline state • Costly
• Accurate • Claustrophobic
• Wide field of view • Difficult in obese patients
• Multiplanar images
• Noninvasive
• No radiation exposure
Bone scintigraphy • Assess metastatic bone disease • Nonspecific
(technetium99m, • Distinguish acute versus old pars
gallium-67 citrate, interarticularis fractures
indium-11 White
Blood Cell (WBC) scan)
Discography • Provocative test reflects • Discography is controversial
symptomatic changes in and its use should be
the Intervertebral Disc (IVD) selective
• Abnormal discogram results • Risks include infection,
in the reproduction of radicular pain, headache,
back/neck pain with the iatrogenic disc degeneration,
same character/distribution or herniated disc
• Dye extravasates from the
confines of the disc space
through tears of the annulus
fibrosus
• Indications include persistent
nonradicular pain suspicious
of discogenic etiology and
preoperative evaluation prior
to a spinal fusion
54 I Patient Evaluation and Spine Overview
a. Plain radiographs show aging and degenerative processes in virtu-
ally all individuals after the age of 40 years (Fig. 3–1).
b. MRI findings of the cervical spine demonstrate
(1) Fourteen percent of asymptomatic individuals 40 years old
and 28% 40 years old had evidence of a herniated disk
(2) Degenerative disk disease is more common in asymptomatic
individuals with an incidence of 25% for 40 years old and 56%
for 40 years old.
c. MRI findings of the lumbar spine demonstrate
(1) In asymptomatic individuals, a herniated disk was noted in 21%
of patients between 20 and 39 years of age and 36% for individ-
uals 60 years of age.
Figure 3–1 Lateral radiograph of the lumbar spine demonstrating a vacuum disk sign at L4–L5.
This is suggestive of disk space collapse and disk degeneration.
Chapter 3 Spinal Imaging and Diagnostic Tests 55
(2) Spinal stenosis is found in 21% for 60 years of age and bulging
disks are found in 50% of patients in all age groups.
II. MRI (Fig. 3–2)
A. Contraindications
1. Ferrous metal implants in the brain
2. Metal debris in the eye
3. Inner ear implants
4. Pacemakers
B. Imaging around metal implants is poor unless special techniques are used
and if the metal is titanium instead of stainless steel.
C. T1- versus T2-weighted images take advantage of intrinsic tissue proper-
ties (Table 3–2)
Figure 3–2 MRI (T2 sagittal image) of the lumbar spine with decreased signal intensity at the
L4–L5 and L5–S1 interspace with minimal loss of disk height.
Table 3–2 MRI Findings of Human Tissue
Tissue Type T1 Signal T2 Signal
Cortical bone Low Low
Tendon/ligament Low Low
Hyaline cartilage Intermediate Intermediate
Free water Low High
Adipose High Low
Abscess Intermediate High
56 I Patient Evaluation and Spine Overview
1. Repetition time (TR)—time between radiofrequency (RF) pulses
2. Echo time (TE)—time between RF and recording
3. T1-weighted image: short TR (400 to 600 ms), short TE (5 to 30 ms)
4. T2-weighted image: long TR (1500 to 3000 ms), long TE (50 to 120 ms)
D. Special indications
1. Postoperative scar versus recurrent disk herniation
a. Use of gadolinium contrast
b. The scar is vascular and enhances with gadolinium. The disk does not
enhance with contrast agents. This is observed on T1-weighted sequence
2. Infection versus tumor
a. In spinal osteomyelitis, there is abnormal tissue with decreased signal
intensity on T1-weighted images and increased signal intensity on T2-
weighted images at the disk margin.
b. In tumors, the intervertebral disk is spared, and similar changes are
noted involving the entire vertebral body.
3. Compression fractures versus pathologic fractures
a. More difficult to differentiate
b. In pathological fractures
(1) Entire vertebral body involvement
(2) Frequent involvement of the pedicle
(3) Presence of soft tissue masses
(4) Canal compromise
c. In osteoporotic compression fractures
(1) Pedicle is not involved.
(2) Partial involvement of the vertebral body
4. Spinal cord injury
a. Distinguishes spinal cord edema versus hemorrhage
(1) Edems is bright on T2 and decreased on T1weighted image
(2) Hemorrhage is bright on T1 and T2 weighted images
E. Disk degeneration (Figs. 3–3, 3–4)
1. Radial tear of the anulus fibrosus is outlined as a fissure extending
from the nucleus to the periphery.
a. High-intensity zone in the posterior anulus suggests a radial tear
that may be clinically significant.
2. Modic end plate changes
a. Type 1
(1) Low intensity on T1-weighted image and high intensity on T2-
weighted image
(2) Associated with segmental spine instability and pain
b. Type 2
(1) High intensity on T1-weighted image and normal on T2-
weighted image
(2) Fatty marrow changes around the end plates
(3) Less likely to be symptomatic
c. Type 3
(1) Hypointense on T1- and T2-weighted images
(2) Sclerotic advanced degenerative changes with less segmental
motion
Chapter 3 Spinal Imaging and Diagnostic Tests 57
Figure 3–3 Axial cut (computed tomography scan) at L4 that demonstrates the pedicles and bony
anatomy. Note the thecal sac can be visualized as well.
Figure 3–4 (A) Lateral discogram demonstrating extravasation of dye at the L5–S1 level sugges-
tive of an anular tear. (B) Computed tomography post-discography (sagittal) demonstrating
extravasation of dye posteriorly at L4–L5.
A
B