Thoracic and Lumbar Spine Special Tests and Pathologies.ppt...

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Unformatted text preview: Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C Clinical Evaluation Spring Test: Test Positioning: Action: Subject is prone Examiner stands with thumbs or hypothenar eminence over the spinous process of a lumbar vertebrae Apply a downward “springing” force through the spinous process of each vertebrae to assess anteriorposterior motion Positive Finding: Increases or decreases in motion at one vertebrae compared to another (hypermobility or hypomobility) Clinical Evaluation Nerve Root Impingement: Narrowing of intervertebral foramen: Stenosis Facet joint degeneration Herniated intervertebral disc Clinical Evaluation Clinical Evaluation Nerve Root Impingement Tests: Valsalva Test: Test Position: Action: Subject takes a deep breath and holds while bearing down as if having a bowel movement Positive Finding: Patient seated, examiner standing next to patient Increased spinal or radicular pain due to ↑ intrathecal pressure May be secondary to a space-occupying lesion (i.e. herniated disc, tumor, osteophyte in lumbar canal) Comments: Increase in intrathecal pressure may result in ↓ pulse, ↓ venous return, ↑ venous pressure (dizziness and/or fainting) Clinical Evaluation Nerve Root Impingement Tests: Milgram Test: Test Position: Action: Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the position for 30 seconds Positive Finding: Patient supine, examiner at feet of the patient Patient unable to hold position, cannot lift the leg, or has pain with test Implications: Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar nerve root Clinical Evaluation Nerve Root Impingement Tests: Kernig’s Test: Test Position: Action: Patient performs a unilateral active straight leg raise with the knee extended until pain occurs After pain occurs, the patient flexes the knee Positive Finding: Patient supine, examiner at side of patient Pain in the spine and possibly radiating into lower extremity Pain relieved when patient flexes the knee Implications: Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meninges Clinical Evaluation Nerve Root Impingement Tests: Kernig/Brudzinski Test: Patient actively flexes the cervical spine (lifts the head) Hip unilaterally flexed (no more than 900) Knee than flexed to no more than 900 (+) ↑ pain with neck and hip flexion; pain relieved when knee is flexed Clinical Evaluation Nerve Root Impingement Tests: Unilateral Straight Leg Raise Test (Lasegue Test): Test Position: Patient supine, examiner standing at tested side with the distal hand around the subject’s heel and proximal hand on subject’s distal thigh (anterior) – maintains knee extension Action: Examiner slowly raises the leg until pain/tightness noted or full ROM is obtained Slowly lower the leg until the pain or tightness resolves, at which point dorsiflex the ankle and have subject flex the neck Clinical Evaluation Straight Leg Raise Test: Positive Findings: Leg and/or low back pain occurring with DF and or neck flexion is indicative of dural involvement and/or sciatic nerve irritation Lack of pain reproduction with DF and/or neck flexion is indicative of hamstring tightness or SI pathology Clinical Evaluation Nerve Root Impingement Tests: Well Straight Leg Raising Test: Can be used to differentiate between sciatic nerve irritation or a herniated intervertebral disc that is irritating the nerve root Test Position: Patient supine, examiner standing at unaffected side; one hand grasps under the heel while other is placed on anterior thigh to stabilize the leg in extension Clinical Evaluation Well Straight Leg Raise Test: Action: Examiner raises the leg by flexing the hip until discomfort is reported (knee kept in full extension) Positive Finding: Pain is experienced on the side opposite that being raised Clinical Evaluation Nerve Root Impingement Tests: Quadrant Test: Test Position: Patient standing with feet shoulder width apart Examiner stands behind the patient, grasping the patient’s shoulders Action: Patient extends the spine as far as possible, than sidebends and rotates to affected side Examiner provides overpressure through the shoulders, supporting the patient as needed Clinical Evaluation Nerve Root Impingement Tests: Quadrant Test: Positive Findings: Reproduction of patient’s symptoms Implications: Radicular pain indicates compression of the intervertebral foramina that impinges on the lumbar nerve roots Local pain (not radiating) indicates facet joint pathology Symptoms isolated to the area of the PSIS may indicate SI joint dysfunction Clinical Evaluation Nerve Root Impingement Tests: Slump Test: Test Position: Patient sits over edge of table; examiner is at side of patient Action: (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping cervical spine neutral (2) Patient flexes cervical spine; Clinician holds patient in this position (3) Knee is actively extended (4) Ankle is actively dorsiflexed (5) Repeat on opposite side Clinical Evaluation Slump Test: Positive Findings: Sciatic pain or reproduction of other neurological symptoms Implications: Impingement of the dural lining, spinal cord, or nerve roots Note: Patient performs ACTIVE knee extension and Clinical Evaluation Test for Patient Malingering: Malingering – medical and psychological terms that refers to an individual fabricating/exaggeratin g their level of symptoms Financial compensation (fraud) Avoiding work Obtaining drugs Attract attention or sympathy Clinical Evaluation Test for Patient Malingering: Hoover Test: Test Position: Action: Patient supine Examiner at feet of patient with hands cupping the calcaneous of each leg Patient attempts to actively straight leg raise on the involved side Positive Findings: Patient does not attempt to lift the leg and examiner does NOT sense pressure from the uninvolved leg pressing down on the hand Patient is not attempting to perform the test Clinical Evaluation Test Note: Examiner should be standing at feet of patient with their hands cupping the heels of each Clinical Evaluation Lower Quarter Neurological Screen Nerve Root Level L1 L2 L3 L4 L5 Sensory Testing Inguinal area (just below inguinal ligament Mid-thigh (medial) Medial knee (just above superior pole of patella) Medial aspect of lower leg, medial ankle, big toe Top of foot (an/or blow head of Clinical Evaluation Lower Quarter Neurological Screen Nerve Root Level L1 L2 L3 L4 L5 S1 S2 Motor Testing Hip flexion Hip flexion Knee extension Dorsiflexion Great toe extension Plantarflexion NA Clinical Evaluation Lower Quarter Neurological Screen Nerve Root Level L4 L5 S1 S2 Reflex Testing Patellar Tendon Patellar Tendon Achilles Tendon Achilles Tendon Clinical Evaluation Babinkski’s Test: Test Position: athlete supine Athletic Trainer Position: At the foot of the athlete holding a blunt tool (reflex hammer) Procedure: Rub the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe. Positive test: Great toe extends while other toes splay. Implications: Lesion of upper motor neurons, may be caused by trauma to the brain Comments: This reflex occurs naturally in newborns. However, this reflex should cease quickly after birth. Clinical Evaluation Erector Spinae Muscle Strain: Common low back pathology MOI: Signs/Symptoms: History of heavy or repetitive lifting Aching back Pain ↑ with passive and active flexion, resisted extension Neurological Evaluation: Negative results Clinical Evaluation Facet Joint Dysfunction: Pathology of facet joints – 40% of all chronic low back pain Vague signs/symptoms: Often resemble other low back pathologies (i.e. strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration) Involvement: Dislocation/sublocation of facet: Facet joint syndrome: (inflammation) Tends to “lock” the involved spinal segment (hypomobile vertebrae) Causes: repetitive stress through movement or loading Degeneration: (arthritis) Causes: undefined history ↓ intervertebral foramen size (nerve root impingement) Clinical Evaluation Facet Joint Dysfunction: History: Inspection: Onset – insidious Pain characteristics – localized MOI – extension, rotation, lateral bending of vertebrae Predisposing conditions – repeated motions of spinal extension, rotation, lateral bending Patient may assume posture that ↓ pressure on affected facets Palpation: Possible local muscle spasm (paravertebral muscles) Clinical Evaluation Facet Joint Dysfunction: Ligamentous Tests: Neurological Tests: Spring Test – pain, ↓ motion Not applicable unless secondary nerve root impingement occurs Special Tests: Quadrant Test (+) Intervertebral disc lesions (-) Clinical Evaluation Facet Joint Dysfunction: Initial Treatment: NSAIDs Instruct patient to avoid postures/movements that irritate facets Modalities – moist heat, e-stim, ice to ↓ muscle spasm Therapeutic Exercises: Stretching and strengthening: Low back Abdominals Hip flexors, hip extensors, hamstrings Clinical Evaluation Intervertebral Disc Lesions: Disc Degeneration: Loss of water from nucleus pulposus ↑ stress load on annulus fibrosus ↓ cushioning ability Small tears occur to annulus (scar tissue formation – not as strong as normal tissue) Bulging of nucleus pulposus Clinical Evaluation Intervertebral Disc Herniation: Extrusion of nucleus pulposus through annulus fibrosus Impingement/pressur e on nerve root below affected disc Sequestrated – nuclear material breaks away from rest of disc MRI lumbar image: L5/S1 disc has suffered a 9mm disc extrusion (red arrow) that is not contained by the PLL L4/5 disc has suffered a smaller 4mm disc protrusion (green arrow) that is contained by the PLL L3/4 (blue arrow) is completely normal and has no disc material projecting posteriorly into the epidural space Note: L3/4 disc is white in color, which indicates it is non-degenerated (i.e., full of water and healthy proteoglycan) Herniated discs (L4/5 & L5/S1) are "black" which indicates Clinical Evaluation Clinical Evaluation Lumbar Disc Degeneration: History: Onset – insidious or may be related to single episode Breakdown of disc is related to repetitive stress; Last episode – final failure an annulus fibrosus to contain nucleus pulposus Pain characteristics – affected vertebrae; compression of spinal nerve root leads to pain in low back, buttocks, radiating into thigh, calf, heel, foot MOI – repetitive loading of disc Predisposing condition – history of lumbar spine trauma Clinical Evaluation Lumbar Disc Degeneration: Inspection: Slow GAIT Flattened lumbar spine Changes in body position – guarded and painful Standing position: Sitting → standing / sitting → lying Changes in disc pressure Lateral shift away from side of leg pain Palpation: Musculature spasm Clinical Evaluation Lumbar Disc Degeneration: Functional Tests: Neurological Tests: Lower quarter screen Special Tests: Limited ROM in all directions Movement in one direction may relieve or ↓ symptoms Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension tests Diagnostic Tests: MRI Clinical Evaluation Intervertebral Disc Degeneration: Surgery Spinal Fusion: Welding 2 or more vertebrae together Cause of back pain (motion between vertebral segments) spinal fusion may be a way to prevent motion and stop the pain Technique (basics): Small pieces of extra bone fills space between two vertebrae (pelvic bone, allograft bone) Disc removed Wires, rods, screws, metal cages or plates may be used Clinical Evaluation Clinical Evaluation Artificial disc replacement: Disc is placed in the disc space through an abdominal incision; the artificial disc then maintains mobility in the spine and as such protects the adjacent disc from accelerated degeneration and further surgery Clinical Evaluation Cauda Equina Syndrome: Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus medullaris CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function properly Numbness, loss of sensation (damage usually permanent) Congenital causes: Spina bifida (abnormality in closure of spinal canal) Tumors of the cauda equina Acquired causes of Cauda Equina Syndrome: Injury (spinal fractures) Secondary to medical procedures Clinical Evaluation Femoral Nerve Stretch Test: Tests for nerve root impingement at L2, L3, L4 Test position: Action: Patient prone with a pillow under the abdomen; examiner at side of patient Examiner passively extends hip while keeping knee flexed to 900 Positive test: Pain in anterior and lateral thigh Clinical Evaluation Sciatica: General term for any inflammation involving sciatic nerve Causes: Lumbar disc herniation SI joint dysfunction Scar tissue around nerve root Nerve root inflammation Spinal stenosis Synovial cysts Cancerous or noncancerous tumors Clinical Evaluation Sciatica: Signs and Symptoms: Special Tests: Radiating pain Muscular weakness Straight leg raise test Tension sign Treatment and Rehab: Resolve pathology that is irritating nerve Oral anti-inflammatory meds / corticosteroids Exercises for strength / ROM Clinical Evaluation Tension Sign: Tests for sciatic nerve irritation Test position: Action: Patient supine; examiner’s one hand grasps the heel while other grasps the thigh Hip and knee flexed to 900 Knee is then extended as far as possible with the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal space Positive finding: Tenderness and reproduction of sciatica symptoms Clinical Evaluation Clinical Evaluation Bowstring Test: (Cram Test) Test position: Action: Patient supine Examiner performs a passive straight leg raise on involved side If subjects reports radiating pain, examiner flexes the subject’s knee to approximately 200 in attempt to reduce pain Pressure than applied to popliteal area to reproduce radicular pain Positive finding: Painful radicular reproduction with popliteal compression Indicates sciatic nerve tension Clinical Evaluation Spondylolysis: Defect in pars interarticularis (area between inferior and superior articular facets) MOI – repetitive stress Unilateral or bilateral defects Listhesis: Posterior portion of the vertebrae, laminae, inferior articular surfaces, spinous process separates from vertebral body “Collared Scotty dog” deformity Symptoms: Localized mow back pain (↑ during/after activity) Pain with extension Clinical Evaluation Spondylolisthesis: Progression of spondylolysis → separation of vertebrae (superior vertebrae slides anteriorly on the one below it) “Decapitated Scotty dog” deformity: Head of the dog (anterior element of vertebrae) has become detached from body (posterior element) Severity – amount of anterior displacement Epidemiology: Most prevalent in women and adolescents Young gymnasts Lateral view of the lumbar spine: Bilateral break in the pars interarticularis (spondylolysis - black arrow) L5 vertebral body (red arrow) has slipped forward on the S1 vertebral body (blue arrow – spondylolisthesis) Normal pars interarticularis - white arrow. Degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 (Grade1-Grade 2 spondylolisthesis) Clinical Evaluation Spondylolysis and Spondylolisthesis: History: Onset of pain: Characteristics: Repetitive stress (extension) Predisposing conditions: Lumbar pain, radiating into buttocks and upper posterolateral thigh MOI: Insidious; pain begins as an ache, ↑ to constant pain Muscular imbalances Repetitive hyperextension activities Inspection: ↑ lordotic curve Altered GAIT Clinical Evaluation Spondylolysis and Spondylolisthesis: Palpation: Step-off deformity may be felt Spasm of paraspinal muscles Functional Tests: AROM: PROM: Flexion – restricted, pain free Extension – pain Rotation and bending - pain Hip flexion – hamstring tightness RROM: Weakness of spinal erectors Clinical Evaluation Spondylolysis and Spondylolisthesis: Special Tests: Pain with Spring test SL stance test; straight leg raises may produce pain Neurological Exam: Lower quarter screen (results typically negative) Comments: X-ray, CT, MRI (will differentiate between spondylolysis and spondylolisthesis) Clinical Evaluation Single Leg Stance Test: Test position: Action: Patient standing with body weight evenly distributed between the 2 feet; examiner stands behind pt. Patient lifts one leg, then places the trunk in hyperextension; examiner may assist Positive test: Pain in lumbar spine or SI area Clinical Evaluation Single Leg Stance Test: Implication: Shear forces are placed on pars interarticularis by iliopsoas pulling the vertebrae anteriorly Comments: Unilateral fracture – pain when opposite leg raised Bilateral fractures – pain with either leg being fractured Clinical Evaluation Sacroiliac Dysfunction: History: Onset: Pain characteristics: One or both SI joints; possibly radiating pain in buttocks, groin, thigh Mechanism: Acute or insidious Prolonged stress Predisposing conditions: Postpartum women (relaxin levels) Hormonal levels during menstruation Clinical Evaluation Sacroiliac Joint Dysfunction: Inspection: Palpation: Trunk flexion (with knees extended) will cause movement of the sacrum on the ilia (pain) Neurological testing: Pain over SI joints and PSIS Functional tests: Levels of iliac crests, ASIS, PSIS Lower quarter screen Special tests: Long sit; SI compression and distraction; straight leg raising; fabre; gaenslen’s; quadrant Clinical Evaluation Sacroiliac Joint Stress Test: Test position: Action: Subject supine; examiner stands next to subject and with arms crossed, places heel of both hands on the subject’s ASISs Examiner applies outward and downward pressure with the heels of both hands Positive finding: Unilateral pain at SI joint or in gluteal/leg region is indicative of anterior SI ligament sprain Clinical Evaluation Sacroiliac Joint Stress Test: Test position: Action: Subject side-lying; examiner stands next to patient and places both hands (one on top of the other) directly over the subject’s iliac crest Apply downward pressure Positive finding: Increased pain indicative of SI pathology (possible involvement of posterior SI ligament) Clinical Evaluation Sacroiliac Joint Stress Test: Test position: Action: Subject lying supine; examiner places both hands on lateral aspect of subject’s iliac crests Apply inward and downward pressure Positive finding: Increased pain indicative of SI pathology (possibly involving posterior SI ligaments) Clinical Evaluation Sacroiliac Joint Stress Test: Test position: Action: Subject lying prone; examiner places both hands (one on top of the other) over subject’s sacrum Apply downward pressure on sacrum Positive finding: Increased pain indicative of SI pathology Clinical Evaluation Patrick or FABER Test: Test position: Action: Subject supine Examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table Positive test: Involved lower extremity does not abduct below level of uninvolved side SI pathology, iliopsoas tightness Clinical Evaluation Gaenslen’s Test: Test position: Action: Subject supine, lying close to edge of table; examiner stands at side Slide patient to edge of table; patient pulls far knee up to the chest; near leg allowed to hang over edge of table Examiner applies downward pressure on near leg, forcing it into hyperextension Positive finding: Pain in SI region indicating SI joint dysfunction Clinical Evaluation Long-Sitting Test: Test position: Action: Subject supine, both hips and knees extended; examiner standing with thumbs on subject’s medial malleoli Ex...
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