Spine History and Physical Exam

• The lecture covers the history and physical exam of the spine.
• Matthew Heller, D.O., FAOASM, presents the lecture.
• Dr. Heller is an Associate Professor, Family and Sports Medicine at NYIT College of Osteopathic Medicine.
• He is also a Team Physician for NYIT Athletics and a Ringside Physician.

Session Objectives

• Demonstrate history taking and perform a physical examination of the spine.
• Describe subjective and objective findings related to the spinal examination.
• Differentiate between normal and abnormal examination findings.
• Recall how to document normal and abnormal findings from the history and physical examination.
• Incorporate Osteopathic Manipulative Medicine (OMM) into case studies.

The Health History

• Common or concerning symptoms include joint pain, neck pain, and low back pain
• Joint pain can be articular or extra-articular, acute or chronic, inflammatory or noninflammatory, localized or diffuse, monoarticular, or polyarticular.
• Joint pain may be associated with constitutional symptoms, such as fever, chills, rash, weight loss, and weakness, and systemic manifestations from other organ systems.

History of Low Back Pain

• Key questions include the pain's location (midline or off-midline)
• Determine if radiation extends into the buttock or lower extremity.
• Ascertain presence of numbness or paresthesia.
• Note if leg pain resolves with rest and/or lumbar forward flexion.
• Assess associated bowel or bladder dysfunction.
• Identify "Red Flags" that indicate serious underlying systemic disease.

History Taking for Back Pain

• Assess any decreased or limited movement.
• Timing should be determined including whether acute or chronic.
• Clarify what aggravates or relieves the pain.
• Note if any systemic features are present, including fever, chills, rash, fatigue, anorexia, weight loss, and weakness.

"Red Flags" for Low Back Pain

• Age over 50 years or under 20 years warrants further investigation.
• A history of cancer is a red flag.
• Additional red flags include unexplained weight loss, fever, or a decline in general health.
• Pain lasting more than 1 month, and that doesn't respond to treatment, should raise concerns.
• Pain at night or increased by rest can be a red flag.
• History of IVDA (Intravenous Drug Abuse), addiction, or immunosuppression indicates attention is needed
• Active infection or HIV is always a red flag and requires review
• Long-term steroid therapy is considered a red flag
• Saddle anesthesia, bladder or bowel incontinence warrants further investigation
• Neurologic symptoms or progressive neurologic deficit indicates attention is needed

Common Review of Systems

• Constitutional symptoms include fever, chills, or fatigue.
• Dermatological review includes rash or sores.
• HEENT review includes head injury, blurry vision, ear pain, or sinus pain.
• Note any neck pain during your review.
• Respiratory review includes shortness of breath (SOB) or difficulty breathing.
• Cardiovascular review includes chest pain or palpitations.
• Gastrointestinal review includes nausea, vomiting, diarrhea, constipation (N/V/D/C), and abdominal pain.
• Peripheral vascular assessment includes noting any varicose veins.
• Musculoskeletal review includes any other joint pain or muscle pain/weakness.
• Neurological review includes numbness, tingling, weakness, saddle anesthesia, or loss of bowel and bladder control.
• Endocrine review includes excessive thirst, hunger, or urination.
• Genitourinary review includes frequency, urgency, dysuria, and discharge.
• Psychiatric review includes depression or anxiety.

Physical Examination of the Spine

• The examination should follow a systematic approach.
• Inspection involves visual examination.
• Palpation involves physical touch to assess different things
• Range of Motion includes active and passive movements.
• Strength testing and special tests should be performed.

Assessing Inflammation

• Assess for swelling.
• Assess for warmth.
• Assess for redness.
• Assess for pain or tenderness that is either Diffuse or Focal

Cervical Spine Inspection

• The inspection should reveal sufficient cervical lordosis.
• Assess the patient’s posture.
• Assess the positioning of the head.
• Note any abnormal rotation or side bending.
• The muscle bulk of the trapezius, deltoid, and SCM muscles should be symmetrical.

Cervical Spine Palpation

• Examination can be performed sitting or standing.
• Palpate the spinous processes, noting any pain, swelling, or step-offs.
• Cervical spines with spinous processes that show a step-off or a significant difference in interspinous distance need radiographs.
• Laterally palpate the musculature in the posterior neck.
• Palpate the suboccipital fossae, noting tenderness and somatic dysfunction.
• Check if the greater occipital nerves are tender in patients with chronic headaches.

Cervical Spine Range of Motion

• The neck is the most mobile part of the spine.
• For flexion, give the instruction to bring your chin to your chest.
• For extension, give the instruction to look up at the ceiling.
• For rotation, the instruction is to look over one shoulder, and then the other.
• For lateral bending, the instruction is to bring your ear to your shoulder.
• Cervical Flexion and extension primarily occurs at the OA joint.
• Cervical Rotation primarily occurs at the AA joint.
• Lateral bending primarily occurs at C2-C7.

Active Range of Motion Instructions

• Extension: "Look up at the ceiling."
• Flexion: "Bring your chin to your chest."
• Rotation: “Look over one shoulder, then the other.”
• Lateral Bending: "Bring your ear to your shoulder, then to the other" and ensure they don’t raise the shoulder)

Cervical Spine Range of Motion Norms

• Flexion in the cervical spine should be 60-90 degrees.
• Extension in the cervical spine should be 70-90 degrees.
• Side bending in the cervical spine should be 20-45 degrees.
• Rotation in the cervical spine should be 70-90 degrees.
• Note any pain reproduction, amplitude of motion, and end-feel

Cervical Spine Resisted Range of Motion

• Typically an isometric contraction
• Expect Painful motion, Weakness
• Limited range of motion can be due to stiffness, pain, overuse, and muscle spasm.

Cervical Spine Examination: Neurovascular

• Assess muscle strength.
• Assess sensation.
• Assess deep tendon reflexes.

Cervical Spine Examination: Lhermitte's Sign

• A.K.A. Barber’s chair phenomenon,
• While sitting on the exam table and attempting to actively hold their head upright, it elicits electrical shock sensations down the spine, arms, or legs
• This indicates possible Spinal stenosis, Multiple Sclerosis, ALS, Arnold-Chiari Malformation

Axial Compression Test: Examination

• Standing behind the patient.
• Examiners place both hands on top of patient’s head and exert a downward force with both hands.
• Pain and/or neurological symptoms of the cervical spine and/or upper extremity being reproduced with the compressive force is a positive test.
• Indicates Cervical Nerve Impingement if positive

Foraminal Distraction Test: Examination

• Stand at the side of table facing the patient
• Perform the test once
• Place one hand under the patient's chin and the other under the occiput
• Apply an upward traction force on the cervical spine
• A positive test has pain and/or neurological symptom reduction
• Indicates Cervical Nerve Impingement if positive

Spurling’s Test: Examination

• Test for foraminal compression on a nerve root
• Place one hand on top of the patient’s head and the other on the patient’s shoulder at the affected side
• Proceed to side bend and rotate the patient’s neck TOWARD the side of their pain
• Add slight extension of the patient’s neck
• Exert a downward force on the patient’s spine
• Pain radiating down the arm to which the head is rotated is a positive indication of Cervical radiculopathy.

Common Conditions: Soft Tissue Injuries

• Cervical strain and cervical sprain are common.
• Usually self-limited, meaning it resolves on its own.
• Cervical Somatic dysfunction can cause problems with the Cervical spine
• A headache (cephalgia) can indicate Cervical Somatic Dysfunction
• Burners and stingers can also indicate conditions

Common Conditions: Hard Tissue Injuries

• Osteoarthritis is a common condition where multiple joints and vertebral bony components develop changes associated with OA (osteoarthritis)
• Degenerative disc disease is wear and tear across the disc-vertebrae interface
• Degenerative Disc Disease may associate with aging and loss of water content within the disc

More Urgent Cervical Spine Issues

• Fractures due to moderate forces, disproportional to the physical findings should be noted
• Herniated Discs can indicate high urgency
• Infections are also high urgency
• Inflammatory Conditions should be noted
• Be aware of Thoracic outlet Syndrome and its severity
• Finally Vascular Emergency should be top of mind

Cervical Spine Imaging: The NEXUS Criteria

• A well-validated clinical decision aid that safely rules out cervical spine injury is the NEXUS criteria
• If the 5 criteria are not present, then the C-Spine can be clinically cleared; the criteria are
  • No Neurologic deficit
  • No Spinal Tenderness (Midline)
  • The patient has an Altered Mental Status / Level of Consciousness
  • Intoxication
  • Distraction (painful) Injury

Cervical Spine Imaging: Canadian C-Spine Rule

• The Canadian c-spine rule is used in an Alert and Stable Trauma patient with C-Spine injury that is a concern
• Includes age (over 65 years)
• Includes mechanism of injury
• Low risk factors to allow assessment of ROM
• Includes testing of neck rotation (45 degrees to left and right)

Thoracic-Lumbar Spine: Inspection

• "I'm inspecting your back"
• Note any abnormalities such as:
  • Scars
  • Asymmetry
  • Thoracic and lumbar curves

Thoracic-Lumbar Spine: Palpation

• Palpate on the skin.
• Focus on the thoracic lumbar junction, thoracic spine, and lumbar spine
• Palpate paraspinal muscles and the spinous process of each vertebra with thumbs.
• Evaluate Skin-drag and perform Erythema test.

Thoracic-Lumbar Spine: Range of Motion

• Note Flexion, Extension, Rotation, and Side-Bending.

Thoracic-Lumbar Spine: Active Flexion

• Instruct examiner to bend forward and touch toes
• Note smoothness and symmetry of movement
• Note the range of motion, and the curve in the lumbar area

Thoracic-Lumbar Spine: Active Extension

• Place one hand on the posterior superior-iliac spine
• With fingers pointed to the midline to support the patient's back
• Instruct patient to bend back as far as possible

Thoracic-Lumbar Spine: Passive Rotation

• Place one hand on the patient's iliac crest to stabilize the pelvis
• Place the other hand on patient's opposite shoulder
• Rotate the patient's trunk by pulling the shoulder, and then the hip posteriorly
• Change hand positions and repeats procedure for the opposite side

Thoracic-Lumbar Spine: Active Side Bending

• Stabilize patient's pelvis by placing one hand on the patient's iliac crest
• Instruct patients to lean as far as possible on the ipsilateral side
• Change hand position and repeats procedure for the opposite side

Lumbar Spine: Advanced Exam

• Deep tendon reflexes such as
  • L4 patellar, no L5 response, and S1 Achilles
• Muscle strength is tested by
  • Ankle dorsiflexion L4, great toe dorsiflexion L5, plantarflexion S1
• Sensory tests
  • Medial foot L4, dorsal foot L5, lateral foot S1

Thoracic-Lumbar Spine: Special Tests

• Key tests include Scapular Elevation, Scapular Protraction (Winging), Adson’s Test, Adam’s Forward Bend Test
• More special ones: Stork Test, Straight Leg Raise test, Bragard’s Test, Well (Opposite) Straight Leg Raising, Hoover Test

Scapular Elevation Examination

• The examiner stands behind the patient and places his or her hands on each acromion.
• With arms resting at the side, the patient shrugs his or her shoulders against examiner resistance
• Weakness or pain against resistance indicates Tendonitis

Scapular Protraction (Winging) Examination

• The patient pushes against a wall with both hands with the feet farther away from the wall than the shoulder.
• Scapular winging, pain, and/or weakness during the maneuvers is a positive test, indicating Serratus anterior muscle weakness.

Adson’s Test Examination

• The examiner locates the radial pulse.
• The patient rotates their head toward the tested arm and lets the head tilt backwards (extends the neck) while the examiner abducts/extends the arm.
• The patient is asked to inhale and turn the head toward the affected side
• The disappearance or diminution of the pulse or provocation of symptoms indicates Thoracic outlet syndrome, usually related to the scalene musculature.

Adam’s Forward Bend Test Examination

• The patient stands with feet together.
• The examiner instructs patient to bend spine forward while keeping their feet together, knees straight and their hands hanging at their side.
• Indicates The curve of structural scoliosis is more apparent when the patient forward bends if there is Presence of unilateral rib cage elevation or unilateral lumbar paravertebral muscle prominence.

Stork Test Examination

• Perform Single leg weight-bearing hyperextension test where the patient stands on one leg and then leans backward extending the lower back
  • Positive when The patient experiences pain in the low back, as this stresses the posterior elements of the spine on the ipsilateral side
  • Indicating a possible pars defect / stress fracture, spondylolysis, or facet pathology

Straight Leg Raise Test Examination

• Patient must lie supine and relaxes his/her leg
• The leg with knee extended is passively raised off of the examination table.
• A radicular pain emanating from the low back following the sciatic nerve distribution and usually radiating below the knee on the ipsilateral side indicates Nerve root impingement
• Exam Bilaterally, perform the Uninvolved side first.

Bragard’s Test Examination

• By taking the leg to the point just below the level of the pain and adding dorsiflexion of the foot.
• the L5 portion of the sciatic nerve will be stretched leading to pain and Indicates Nerve Root Impingement

Well (Opposite) Straight Leg Raising Examination

-  Have the patient raise his/her straight leg on the uninvolved side

• If the patient experiences Pain on the side opposite that being raised, then the test is positive for possible space occupying lesion

Hoover Test Examination

• With the patient lying supine, the examiner places a hand under each heel.
• Have the patient lift the affected leg off the table.
• A normal response is for the patient to push downward with the contralateral heel
  • If No downward force is felt, the patient is not giving enough effort when the patient is raising the involved leg

Lumbar Spine- Differential Diagnosis

• Consider Lumbar Strain/Sprain, Herniated nucleus pulposus, Spinal Stenosis, Spondylolisthesis, Spondylolysis, Spondylosis (degenerative disc disease), Compression fracture

Lumbar Spine- Serious Etiologies

• Pay attention of you consider; Cauda Equina Syndrome (CES), Cancer, Fracture, Infection

Case Study Overview

• A 77 y/o male presented with chronic upper and lower back pain for around 10 years, around the time he has been diagnosed with Parkinson's Disease
• He Pain in the lower back bilaterally (3-4/10 on pain scale, described as a dull achy pain and no radiation)
• Previously found to have imaging showing moderate degenerative disc narrowing and small central disc herniation (2015)

Relevant Case Study Information

• The condition is worst after prolonged standing and walking but improves with rest.
• There is no weight loss or gain, no fever / chills, no loss of appetite, no fatigue, and there is difficulty sleeping.
• Medications include Selegiline 5mg bid, amlodipine 5mg daily, and claritin 10mg as needed.
• Parkinson's Disease was diagnosed 10 years ago, and Hypertension has been around since age 55

Case Study Physical Examinations

• Vitals: BP- 124/80, HR 74, RR 14, Temp. 97.9, Weight- 165 pounds, Height- 72 inches, BMI- 22.38, Pulse Ox- 98% room air
• HE has normal mental status with hypophonic and tachyphemic speech. Motor strength is limited by increased tone bilaterally
• The Thoracic spine has a head forward and rounder shoulder posture, with no vertebral spine tenderness, and increased Thoracolumbar spinal flexion is seen
• On Palpation sub-occipital hypertonicity, cervical Upper trapezius, Thoracic paravertebral muscle hypertonicity, and Lumbar paravertebral muscle hypertonicity was found

Case Study Findings and Treatments

• OMT was used effectively to counter sub-occipital findings, cervical and Lumbar
• Improved by treating: Sub-occipital release, BLT indirect, Facilitated Positional Release, Myofascial release, BLT indirect
• The assessment had multifactorial etiology, Degenerative Disc Disease, Herniated Disc
  • Multiple Somatic Dysfunctions Cranial, Cervical, Thoracic, Lumbar, PErkinsons Disease, and Camptocormia

Case Study Plan

• OMM treatment done today in office
• Proper hydration and healthy nutrients
• May apply heat as needed
• Back stretches and ROM exercises advised
• Continue current Physical Therapy for improvements in balance and gait
• Tylenol / NSAIDs as needed for pain
• Will consider getting repeat imaging if symptoms persists or worsens
• Follow up in 1 week, sooner if symptoms worsens

Additional Case Study Progress Notes

• After Osteopathic treatment at the 2nd visit, 11 days after initial visit
  • The patient felt better and was able to fully lift his back to an upright position.
• After Osteopathic treatment at the 3rd visit, 18 days after initial visit
  • The patient was able to stand tall and look at the sky.