GENERAL PRINCIPLES
PHYSICAL EXAMINATION
Physical examination of the spine includes:
• A general inspection, static and dynamic, in the standing position
• Range of motion assessment in flexion, extension, rotation, and side bending of the cervical, thoracic, and lumbar regions
• The segmental examination (Maigne) to assess for any specific painful segments
General Inspection: Static
The patient should be standing comfortably with the legs extended. Curvature abnormalities in both the frontal and sagittal planes should be looked for. The patient is examined:
• From the rear: both shoulders, the top of the scap-ulae, and the iliac crest should be on the same hor-izontal plane with respect to the sagittal bisector formed by the spinous processes (Fig. 20.1).
• From the front: the anterior superior iliac spines should both be on the same horizontal plane (Fig. 20.1).
• From the side: the sagittal curvatures are examined with a plumb line held tangentially at the top of the
thoracic kyphosis to determine the sizes of the cur-vatures. The static examination is completed with a study of the lower limbs, including thighs, legs, and feet.
This examination can reveal abnormalities of the cur-vatures in the frontal or sagittal plane.
Frontal Plane Anomalies
Frontal plane anomalies are due to (a) scoliosis or pseudoscoliosis and (b) antalgic posturing.
Antalgic posturing — During an acute episode of low back pain, with or without sciatica, the patient may man-ifest a lateral lumbar shift either ipsilateral or contralateral to the painful side. Often, there is a loss of lumbar lordosis and, occasionally, a lumbar kyphosis. This posturing is involuntary and nonreducible, either actively or passively, and can be distinguished from true scoliosis by the lack of a rotatory component to the involved vertebrae. The lumbar shift is thought to arise from positioning the spine in a manner that decreases the pain, and it is maintained by involuntary muscle guarding. These findings resolve spontaneously with resolution of the factors that led to the acute attack (Fig. 20.2).
Scoliosis and pseudoscoliosis — In pseudoscoliosis, there is no rotoscoliosis. The curve asymmetry corrects when the patient bends forward at the waist while keeping the knees extended (Fig. 20.3). A leg length discrepancy can produce static postural asymmetry resulting in obliq-uity of the sacral base and a convexity in the frontal plane.
A wedge placed under the short limb levels the pelvis and the pseudoscoliosis resolves (Fig. 20.4 and Fig. 20.5).
In true scoliosis, there is a rotatory component to the involved segments that produce the characteristic gibbous deformity. Furthermore, the scoliotic curve does not resolve in forward bending (Fig. 20.6). Radiographs per-formed in the prone or supine position can distinguish between scoliosis and pseudoscoliosis, as the latter con-dition corrects in nonweight-bearing positions, while the former does not. The major curve and the minor (com-pensatory) curve are clearly delineated radiographically.
The scoliotic deformity may be either balanced or unbalanced. In a balanced scoliosis, a plumb line dropped from the spinous process of C7 falls in the midline between the two gluteal folds; in an unbalanced scoliosis, the same plumb line falls to one side of the midline (Fig. 20.7).
The degree of scoliosis may be assessed clinically in terms of the gibbous deformity that manifests in forward flexion. This can best be appreciated when the examiner stands behind the patient and inspects tangent to the spinous processes (Fig. 20.6). This angle can be measured radiologically by the Cobb method in which lines are extended tangentially to the superior or inferior endplate of the most inclined superior and inferior vertebrae,
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respectively. The angle formed by the intersection of per-pendiculars dropped from each of these two lines is the Cobb angle, which represents the angle of curvature of the scoliosis (Fig 20.8).
Most cases of scoliosis may be classified as idiopathic (80%). The curve may be thoracic, lumbar, thoracolumbar, or appear in two of the above regions.
Sagittal Plane Anomalies The sagittal plane curves may be:
• Exaggerated, resulting in lumbar hyperlordosis or thoracic hyperkyphosis
• Attenuated, producing a “flat back”
• Reversed, resulting in lumbar kyphosis and thoracic lordosis
A thoracic kyphosis is considered to be excessive when the angle of curvature exceeds 50°. The measurement is
made from a lateral upright radiograph of the thoracic spine. Kyphotic curves can be separated into those curves with a smooth gradual angular deformity as well as those with acute angulation (Stagnara).
The apex of the thoracic kyphosis usually is situated at T7–8 where the plumb line rests tangential to the spine (Fig. 20.9). The perpendicular distances from the plumb line to the C7 and L3 spinous processes can be measured readily, and in the adult, usually equal 60 and 90 mm, respectively. The angle of curvature of the kyphosis can be derived radiographically at the intersection of tangen-tial lines extending from the superior and inferior end-plates of the upper- and lowermost vertebrae of the curve, respectively. Photographic techniques are also used to assess the degree of kyphosis. The subject is upright and photographed in side view against a background grid of 5-cm squares.
Kyphosis is of clinical significance in the adolescent population, with the most common presentation being
Figure 20.1 a. Posterior view of a patient standing with legs spread slightly shows that the right and left shoulders, the angle of the scapula (right and left), the iliac crest (right and left), and the iliac spine (right and left) are all level. b. Anterior view showing the biclavicular line of the shoulders and the horizontal line of the iliac spine anteriorly and superiorly.
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Figure 20.2 Antalgic posture or painful scoliosis. A lateral lumbar shift can be due to protective muscle guarding as is seen in sciatica resulting from disk disease or acute low back pain.
Figure 20.3 a. Scoliotic posture. b. It disappears with for-ward flexion. There is no rotation of the vertebrae.
Figure 20.4 Short leg can be responsible for scoliotic posture.
Figure 20.5 A wedge under the foot can re-equilibrate the vertebral spine.
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Scheuermann’s apophysitis. The thoracic spine is most frequently involved, but occasionally the lumbar region is affected. The latter case is most evident with the patient in the seated position, as the lumbar lordosis is replaced by a kyphotic curve.
General Inspection: Dynamic Assessment of Forward Flexion
The patient is asked to bend forward at the waist from the upright position while keeping the legs adducted and the knees extended (Fig. 20.11). One should note:
• A normal lumbopelvic rhythm with smooth reversal of the lumbar lordosis.
• The persistence (as in scoliosis) or the reversal (as in pseudoscoliosis) of any frontal plane anomalies.
• Pain limiting flexion (measured as the distance from fingertips to floor; Fig. 20.12).
• The presence of paraspinal muscle fullness (spasm) or a lumbar shift that may only be present during a small arc of flexion, then resolve with further flex-ion.
• Whether the limitation in flexion (fingertips to floor) is due to painless stiffness of the spinal extensors or
hamstring muscles, this is frequently the case in those subjects with otherwise normal lumbopelvic rhythms. This lack of resiliency can increase the stress on the lumbosacral junction. Conversely, some patients can occasionally touch their fingers to the floor, despite a stiff spine, if the hamstrings are loose enough (Fig. 20.13 and Fig. 20.14).
Schober’s test measures the degree of lumbar excur-sion (see “Examination of Lumbar Spine” in Chap-ter 21). Badelon’s rachimeter can precisely measure the excursion of the spine and the hamstrings (supra-and infrapelvic excursion).
Assessment of Side Bending
In the upright position, with the legs slightly abducted and knees extended, the patient is asked to bend laterally to the right and then to the left, sliding the hand down the leg.
One should note whether the spinal curves are smooth and symmetric from side to side or if any segmental stiff-ness appears that may be more pronounced in one direc-tion, and whether or not this is associated with pain. The fingertip-to-floor measurement may be used to quantify the amount of lateroflexion (Fig. 20.15). Alternatively, the
Figure 20.6 a. True scoliosis is due to a rotation of the ver-tebrae. b. In true scoliosis, forward flexion results in a gibbous deformity that can be measured as the difference between the high and the low points of the back.
Figure 20.7 a. Scoliosis is said to be in equilibrium when a plumb line is able to pass through the middle of the occiput and the natal cleft (intergluteal groove). b. Scoliosis is said to be in disequilibrium when a plumb line does not pass through the middle of the occiput and the natal cleft.
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position where the fingertip overlies the thigh can be com-pared on both sides.
Assessment of Extension
This aspect of the examination is more specifically addressed in the regional spinal assessment. However, a global sense of the degree of extension, the presence or absence of pain or stiffness can be inferred by asking the patient to bend backward with the hips and neck in exten-sion and the shoulders retracted.
Assessment of Rotation
This examination is performed as part of the regional assessment.
Assessment of Regional Mobility
This portion of the examination assesses the compo-nents of triplanar motion made up of flexion and exten-sion, right and left rotation, and right and left lateroflexion.
Each spinal region — cervical, thoracic and lumbar — is assessed.
First, the subject is requested to perform the active range of motion, followed by passive range assessment by the examiner. Attention is given to whether there is any
specific segmental stiffness and which degrees of freedom are restricted or painful.
The degree of discomfort is noted as well as where in the arc of motion it is produced. A “star diagram” (Maigne and Lesage), in which each of the six primary movements is represented by an arrow, is a convenient way to record this information (Fig. 20.16).
Previously, the degree of pain or motion restriction was indicated by hatches (from 1 to 3, according to degree) assigned to the branch of the involved plane of motion.
This diagram can be improved upon by distinguishing painless restriction (–) from painful restriction (×). The positions of the markings on the branch (i.e., the distance from the center) indicate where in the arc of motion the restriction occurs. The intensity of the pain or limitation is indicated by the number of ×’s or strokes, respectively.
A painful but unlimited arc is marked with a circle (Fig.
20.17), Thus, all possible combinations can be readily visualized, and a markedly restricted but painless arc of motion can be distinguished from a marked restriction that is mildly painful (Fig. 20.18 through Fig. 20.20).
Figure 20.8 Measurement of the angles of the scoliotic curves: 1, vertebral upper limit; 2, vertebral lower limit; and 3, vertebral apex. Tangential lines are extended through the endplates of the vertebrae at the superior and inferior limits of the scoliotic curve, which are usually the vertebrae most inclined from the horizontal plane. The angle formed by these two tangential lines is described as the angle of scoliosis (α).
It is easy to obtain this angle by dropping perpendiculars from these tangents, as demonstrated in the drawing.
Figure 20.9 Posture in the sagittal plane is measured by dropping a plumb line tangent to the most posterior part of the spinal column. This apex is usually at approximately T7–T8. From this line, one can then measure the distance between C7 and that line, which in the normal individual is in the range of 30 mm and demonstrates a similar distance at the L3 level.
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Figure 20.10 Subjects with abnormal curves. a. Accentuated curves. b. Attenuated curves. c. Lumbar hyperlordosis.
d. Thoracic hyperkyphosis. (The arrow does not measure the lordosis. One must deduct the sacral distance to obtain the measure of lordosis. In case c, for example, the L4 arrow measures 80 mm, and the S2 arrow measures 20 mm; 80 mm – 20 mm = 60 mm. Thus,. the subject is said to have a measured lordosis of 60 mm.)
Figure 20.11 Forward flexion with legs extended. This motion requires a flexible spine or flexible hamstrings.
Figure 20.12 If the spine is rigid, the lumbar lordosis does not reverse on forward flexion.
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Figure 20.13 Patients who lack hamstring flexibility may have limited forward flexion, as measured by the distance between the fingers and the floor, despite normal vertebral flexibility.
Figure 20.14 Conversely, an individual who has a stiff low back but can stretch the hamstring may be able to easily touch the floor.
Figure 20.15 a. Trunk side-bending produces a smooth C curve of the spinal vertebrae. c. Loss of lumbar mobility translates to an abnormality called the sign of Cassure.
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Segmental Examination
The segmental examination assesses each spinal seg-ment individually. Its purpose is to elicit tenderness in a spinal segment by one or more specific maneuvers. Seg-mental tenderness may be indicative of many different pathologies: mild, severe, benign, or malignant.
The examination should be performed slowly and firmly maintaining at all times an active dialogue with the patient in order to determine the presence or absence of pain associated with palpation.
Often the patient prior to examination may be unaware of painful areas and may insist that their pain is elsewhere.
The examiner should nonetheless perform the full exam-ination in order to determine the exact location and origin of segmental symptoms.
Basic Maneuvers (Fig. 20.21)
The four basic maneuvers of the segmental examina-tion are as follows:
1. Posteroanterior (PA) pressure over the spinous process
2. Transverse pressure against the lateral aspect of the spinous process
3. Longitudinal friction overlying the facet joints 4. Pressure against the interspinous ligament
Figure 20.16 Star diagram of Drs. Maigne and Lesage: E, extension; F, flexion; LLF, left lateral flexion; RLF, right lateral flexion; LR, left rotation; and RR, right rotation.
Figure 20.17 A bar placed on one of the branches of the star is used to mark a limited but nonpainful range of motion.
Depending on the severity of this limitation, one can note one, two, or three bars. × indicates a painful limitation in range of motion. One can note one, two, or three ×’s, indicating increasing severity. A circle indicates a normal range of motion with a painful arc.
Figure 20.18 If one wishes to be more precise in terms of documenting the results of the examination, one can place the bars or ×’s closer or farther from the center according to the level of severity obtained or the movement limitation. In this case, one would place the ×’s closer to the center if they appear early in the movement or farther out along the branch if they occur late in the movement. One would translate this diagram as follows: severe pain on extension at the onset of movement, severe pain on right rotation, and mild pain at the end of right lateral flexion.
Figure 20.19 A region of the spine where the flexion/exten-sion is free, with pain on flexion; right and left lateral flexion and right and left rotation are very limited but not painful.
Figure 20.20 Pain without any free movement.
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PA pressure over spinous process (Fig. 20.22) — This is best performed with the pad of the thumb. Firm, gradual anteriorly directed pressure should be applied to the spinous process and held for a few seconds. It may be preferable to interpose the other thumb between the spinous process and examining thumb.
Transverse pressure against spinous process (Fig. 20.23) — This maneuver can be used for all spinal segments except the cervical segments above C7 and in some cases C2. Slow gradual pressure is applied to both sides of the spinous process, right and left alternately, in the plane of the skin. This maneuver imparts rotation about an oblique axis on the involved vertebral segment. The example in Figure 20.23 depicts vertebra B, which is tender with transverse pressure from right to left or right rotation. Contralateral pressure to either vertebra A above
or C below helps distinguish which of the two motion segments, AB or BC,is involved.
Remarks
It is essential that pressure truly be applied transversely to the spinous process rather than obliquely to the junction of the spinous and transverse processes. The latter maneu-ver can produce false-positive results through irritation of the underlying branches of the posterior rami.
Contralateral Pressure (Maigne)
While applying transverse pressure to a vertebra in the painful direction, the opposite thumb may apply a contralat-eral transverse pressure to the spinous process of the vertebra above or below. Usually, one of these two maneuvers will
Figure 20.21 The four maneuvers of the segmental examination of Maigne. a. PA pressure over the spinous process. b.
Transverse pressure against the spinous process. c. Longitudinal friction overlying the facet joints. d. Pressure against the interspinous ligament.
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increase the tenderness provoked with unilateral trans-verse pressure, allowing for precise localization of the segmental dysfunction. In the example in Figure 20.24, vertebra B is painful to transverse pressure applied from right to left. This pressure on B is maintained while a simultaneous contralateral transverse pressure is applied from left to right. When this counterpressure is applied to vertebra A, the pain is not modified. However, when the same counterpressure is applied to vertebra C, the pain is notably increased. One can conclude that the origin of the provoked pain is segment BC. The most effective position for the thumbs is shown in Figure 20.25.
Longitudinal friction overlying facet joints (Fig. 20.26) — Facet joint tenderness is elicited by lon-gitudinal friction. This maneuver does not provoke pain in the absence of dysfunction involving one (rarely, both) of the facet joints. The friction is applied to the sub-cutaneous tissues and paraspinal musculature that is super-ficial to the facets. In the cervical assessment, the parac-ervical muscles readily relax in the supine position. This facilitates this maneuver, allowing nearly direct palpation of the articular pillars. This direct palpation is not present in the thoracic or lumbar regions. Nevertheless, when longitudinal friction is applied and produces tenderness one fingerbreadth lateral to the midline, the location of the tender point practically always corresponds (except in the midthoracic segments, T4–7) to the facet joint, as has been verified fluoroscopically. This is seen in the context of other signs of segmental dysfunction.
Pressure against interspinous ligament (Fig. 20.27) — Interspinous ligament sensitivity is often seen in spinal segmental dysfunctions. Ligamentous tenderness is elic-ited by transverse friction over the ligament, applied by the pad of the index finger or, preferably, with a key ring.
Precautions and Sources of Error in Segmental Examination
All the maneuvers of the segmental examination should be applied gradually, progressively, and firmly. The exam-ination should be unhurried, repeated, and compared with that of adjacent spinal segments. The pressure applied to each side should be equivalent. Proficiency in these tech-niques requires a degree of practice. Practitioners skilled in these methods consistently concur on the level of seg-mental findings in a given patient.
Faulty examination technique can lead to spurious con-clusions. Excessive and improperly applied pressure can provoke tenderness in normal segments, leading to false positives. More importantly, false negatives occur when insufficient pressure is applied to involved spinal seg-ments.
Errors to avoid:
• Pain with PA pressure on the spinous process may,
• Pain with PA pressure on the spinous process may,