1. Thoracic and Lumbar Spine Clinical Evaluation
Orthopedic Assessment III – Head, Spine, and Trunk with Lab
PET 5609C

2. Clinical Evaluation History: Location of Pain:
Pain radiating into extremities
Peripheral paresthesia or numbness:
Result of impingement or pressure on nerve root exiting intervertebral foramen or dural irritation proximal to pain site
Pain Locations:
Lumbar pain – possible ambiguous cause
Sacroiliac pathology – pain around PSIS or radiating pain in hip/groin
Piriformis spasm – symptoms of sciatic nerve dysfunction

3. Clinical Evaluation

4. Clinical Evaluation History: Onset of Pain: Acute Chronic
Insidious pain onset
Note: Patient may describe a single incident that initiated pain, although trauma is probably an accumulation or repetitive stresses/microtrauma

5. Clinical Evaluation History: Mechanism of Injury:
Movement: Flexion, Extension, Lateral Bending, Rotation
Blunt Trauma: Direct blow to lumbar/thoracic area
Contusions
Compressive Stress:
Hyperextension of spine

7. Clinical Evaluation History: Pain Consistency:
Constant Pain: Unyielding (does not improve with various position of patient’s spine)
Example pathology – Inflammation of dural sheath

8. Clinical Evaluation History: Pain Consistency: Intermittent Pain:
Mechanical Origin – certain spinal positions may ↑ or ↓ pain symptoms
Compression/stretching of nerve root – Increase pain
Positioning (flexion, traction) – lessen the pressure on involved structure

9. Clinical Evaluation History: Bowel or bladder signs:
Does the patient have any bowel or bladder problems?
Incontinence: Loss of bowel or bladder control
May indicate lower nerve root lesions (cauda equina syndrome), or spinal cord injury
Description: urinary incontinence may range from occasionally leaking urine (during cough/sneeze) to having sudden episodes of strong urinary urgency

10. Clinical Evaluation History: Bowel or Bladder Signs:
Cauda Equina Syndrome:
Nerves within the spinal canal have been damaged
Result: nerves supplying the muscles of the legs, bladder, bowel and genitals do not function properly
Patients experience numbness, loss of sensation and pain in the legs, buttocks and pelvic region (damage usually permanent)
Causes:
Spina bifida (abnormality in closure of spinal canal)
Tumors
Injury (spinal fractures)
Intravertebral disc herniation
Vascular (blood vessel) problems or infections of the cauda equina

11. Clinical Evaluation History: History of spinal injury:
Previous injuries:
Structural degeneration
Predisposition to injury
Changes in activity:
Exercise habits (intensity levels, duration, frequency)
Footwear, running surfaces
New bed

12. Clinical Evaluation General Inspection: Frontal Curvature:
Alignment of lumbar, thoracic, cervical vertebrae with patient lying prone or standing
Normal alignment – straight
Abnormal alignment:
Scoliosis – lateral curvature (lumbar and/or thoracic spine)

13. Clinical Evaluation General Inspection: Scoliosis Signs and symptoms:
Uneven shoulders
One shoulder blade appears more prominent
Uneven waist / 1 hip higher vs. other
Leaning to one side
Back pain and difficulty breathing (severe scoliosis)
Causes:
Idiopathic (85% of cases)
Underlying neuromuscular disease, leg-length discrepancy, birth defect, fetal development (congenital)
Not caused by poor posture, diet, exercise, or the use of backpacks

14. Clinical Evaluation Diagnosis: Angle: X-ray
Normal Spine (0 degrees)
Scoliosis: (> 10 degrees)
Complications: (severe scoliosis)
Lung and heart damage: compression of rib cage against heart, lungs
> 70 degrees
Back problems

15. Clinical Evaluation General Inspection:
Scoliosis Test: Adam’s Forward Bend Test
Patient Position: Standing with hands held in front (arms straight)
Evaluation Procedure: Patient bends forward, sliding hands down the front of each leg
Positive Test:
Asymmetrical hump along lateral aspect of thoracolumbar spine
One shoulder blade appears more prominent
Uneven hips
Implications:
Functional scoliosis: scoliosis present when patient stands straight, disappears during flexion
Structural scoliosis: present during both standing and with flexion

16. Clinical Evaluation

17. Clinical Evaluation General Inspection: Sagital Curvature:
Normal Alignment:
Lordotic cervical
Kyphotic thoracic
Lordotic lumbar
Kyphotic sacral

18. Clinical Evaluation

19. Clinical Evaluation General Inspection: Observation of GAIT:
Spinal pain – influence on walking and running gait
Slouching
Shuffling
Shortened gait

20. Clinical Evaluation General Inspection: Skin Markings:
Café-au-lait spots: presence of darkened areas of skin pigmentation
Normal (benign)
Collagen disease
Neurofibromatosis 1
95% of patients will display spots

21. Clinical Evaluation General Inspection:
Skin Markings: Sign of Neurofibromatosis-1
Neurofibromatosis-1:
Autosomal dominant disease
Characterized by formation of neurofibromas (tumors involving nerve tissue) in the skin, subcutaneous tissue, cranial nerves, and spinal root nerves
Implications: growth of tissue along the nerves – puts pressure on affected nerves and cause pain and severe nerve damage
Loss of nerve function (sensation, movement)

22. Clinical Evaluation General Inspection: Breathing patterns:
Irregular breathing (i.e. shallow respirations, pain)
Injury to thoracic vertebrae
Pressure on thoracic nerves
Trauma to ribs, costal cartilage
Bilateral comparison of skin folds:
Asymmetry of natural folds
Causes: muscle imbalance, ↑ or ↓ kyphosis, scoliosis

23. Clinical Evaluation General Inspection: Kyphosis:
Abnormal forward rounding of the upper back (> 40 to 45 degrees)
Round back or hunchback
Causes:
Developmental problems, degenerative diseases (arthritis), osteoporosis with compression fractures, trauma
Severe cases:
Can affect lungs, nerves, causing pain and other problems

24. Clinical Evaluation General Inspection:
Kyphosis Test: Forward bend test
Patient bends forward from the waist while ATC views the spine from the side
With kyphosis, the rounding of the upper back may become more obvious in this position
Postural kyphosis – the deformity corrects itself when patient lies on their back

25. Clinical Evaluation Postural kyphosis: Structural kyphosis:
May improve on its own
Exercises to strengthen back muscles, correct posture, and sleeping on a firm bed
Structural kyphosis:
Caused by spinal abnormalities
Scheuermann's disease:
Developmental disorder that causes a stooped forward or bent-over posture
Affects between 0.5% and 8% of the general population
Osteoporosis-related kyphosis:
Multiple compression fractures
Low bone density

26. Clinical Evaluation

27. Clinical Evaluation General Inspection: Movement and Posture:
Poor posture (standing, sitting, bending)
Lordotic Curve:
Reduction:
Muscle spasm
Hamstring tightness
Increased:
Hip flexor tightness
Abdominal weakness

28. Clinical Evaluation

29. Clinical Evaluation General Inspection: Standing Posture:
Lateral shift in trunk and pelvis
Nerve root impingement (lateral shift ↓ pressure)
Erector Spinae Muscle Tone:
Unilateral hypertrophy or atrophy
Faun’s Beard:
Spina bifida occulta

30. Clinical Evaluation General Inspection: Spina Bifida
Birth defect that occurs when the tissue surrounding the developing spinal cord doesn't close properly
Spina Bifida Occulta:
Mildest form, results in a small separation in one or more of the vertebrae of the spine (spinal nerves usually not involved – most patients have no signs/symptoms or neurological problems)
Inspection: Faun’s Beard, a collection of fat, a small dimple or a birthmark on the newborn's skin above the spinal defect
Complications:
Minor physical disabilities
Mental strain
Severity:
Size and location of the neural tube defect
Does skin cover the area?
Do the spinal nerves come out of the affected area of the spinal cord?

31. Clinical Evaluation

32. Clinical Evaluation Palpation: Thoracic Spine Spinous Processes
Supraspinous Ligaments:
Fills space between the spinous processes
Costovertebral Junction:
Articulation between ribs and thoracic vertebrae
Only palpable on slender individuals
Trapezius:
Origin to insertion
Rhomboids and levator scapulae lie deep to middle/upper traps
Paravertebral Muscles
Scapular Muscles

33. 1 – Spinous Processes
2 – Supraspinous Ligaments
3 – Costovertebral Junction
4 – Trapezius
5 – Paravertebral Muscles
6 – Scapular Muscles

34. Structure
Landmark
Cervical vertebral bodies
Same level as spinous processes
C1 transverse process
One finger’s breadth inferior to mastoid process
C3-C4 vertebrae
Posterior to hyoid bone
C4-C5 vertebrae
Posterior to thyroid cartilage
C6 vertebrae
Posterior to cricoid cartilage; moves during flexion and extension of cervical spine
C7 vertebrae
Prominent posterior spinous process
T1 vertebrae
Prominent protrusion inferior to cervical spine
T2 vertebrae
Posterior from jugular notch of the sternum
T3 vertebrae
Even with the medial border of the scapular spine
T7 vertebrae
Even with the inferior angle of the scapula
L3 vertebrae
Posterior from the umbilicus
L4 vertebrae
Level with the iliac crest
L5 vertebrae
Typically demarcated by bilateral dimples, but variable from person to person S2
At level of the posterior superior iliac spine

35. Clinical Evaluation C7 T1 T2 T3 T4 T5

36. 1 – Spinous Processes
2 – Step-off Deformity
3 – Paravertebral Muscles

37. Clinical Evaluation Spondylolisthesis:
Forward slippage of a vertebrae on the one below it
L4 and L5 / L5 and S1
Affects 5-6% of males, 2-3% of females
Causes:
Strenuous physical activity (weightlifting, gymnastics, football)
Types:
Developmental:
May exist at birth, or may develop during childhood (generally not noticed until later in childhood/adult life)
Acquired:
Degeneration: caused by the daily stresses that are put on spine (i.e. carrying heavy items, physical sports)
Connections between the vertebrae weaken
Single or repeated force

38. Clinical Evaluation Spondylolisthesis: Grade 1: Grade 2: Grade 3:
25% of vertebral body has slipped forward 
Grade 2:
50%
Grade 3:
75%
Grade 4:
100%
Grade 5:
Vertebral body completely fallen off (i.e.,spondyloptosis)

39. Clinical Evaluation Symptoms: May be asymptomatic
Low back pain (especially after exercise)
↑ lordosis
Pain/weakness in one or both legs
↓ ability to control bowel/ bladder functions
Tight hamstrings
Advanced spondylolisthesis: changes may occur in the way patient stands/walks

40. Clinical Evaluation Palpation: Sacrum and Pelvis Median sacral crests
Iliac crests:
Palpate laterally from PSIS to find iliac crests and anteriorly to locate ASIS (level of symmetry)
Posterior superior iliac spine
Gluteals
Ischial tuberosity
Greater trochanter
Sciatic nerve:
Place thumb on ischial tuberosity and 3rd finger on the PSIS. 2nd finger will fall into sciatic notch (nerve most superficial as it passes by ischial tuberosity)
Pubic symphysis

41. 1 – Median sacral crests
2 – Iliac crests
3 – PSIS
4 – Gluteal muscles
5 – Ischial tuberosity
6 – Greater trochanter
7 – Sciatic nerve
8 – Pubic symphysis

42. 1 – Iliac crest
2 – Tensor fascia latae
3 – Gluteus medius
4 – Iliotibial band
5 – Greater trochanter
6 – Trochanteric bursa

43. 1 – Pubis
2 – ASIS
3 – AIIS
4 – Sartorius
5 – Rectus femoris

44. Clinical Evaluation Active Range of Motion: Flexion and Extension:
Measured with patient standing
Distance from the fingertips to the floor can be measured (accuracy affected by tightness of hamstrings and calf muscles and scapular protraction)
Gravity assists with movement
More accurate than hook-lying position
Abdominal muscles have to overcome weight of the trunk

45. Clinical Evaluation Active Range of Motion: Lateral Bending: Rotation:
Patient standing (feet shoulder width apart and the hand opposite the direction of the movement resting on the ilium)
Patient bends trunk laterally (attempt to tough fingertips to the ground)
Distance between the ground and fingertips is measured
Rotation:
Patient is sitting position (stabilizes pelvis and lower extremity)
Patient rotates shoulder girdles and spinal column (attempt to look behind one’s back)
Movement primarily occurs in thoracic spine

46. Clinical Evaluation Passive Range of Motion: Flexion: Extension:
Patient in hook-lying position
Examiner brings the knees to the chest by lifting under the knees and thighs and flexing the hip and thoracic spine
Extension:
Patient prone (hands flat on table at shoulder level – push-up position)
Patient extends arms, lifting the torso (hips and legs remain of table)
Rotation:
Patient’s pelvis and legs are rotated to bring lateral portion of the knee towards the table (shoulders remain flat)

47. Motion Ligaments Stressed
Spinal Ligaments Stressed During Passive Range of Motion Testing
Motion
Ligaments Stressed
Flexion
Posterior Longitudinal Ligament, Supraspinous Ligament, Interspinous Ligament, Ligamentum Flavum
Extension
Anterior Longitudinal Ligament
Rotation
Interspinous Ligament, Ligamentum Flavum
Lateral Bending

48. Clinical Evaluation Beevor’s Sign: Test for thoracic nerve inhibition
Patient performs an abdominal curl-up from hook-lying position
Normal Findings: abdominal muscles receive concurrent innervation from T5-T12 nerve roots (umbilicus does not move)
Positive Test: umbilicus is pulled toward the head
Characteristic of spinal cord injury between T6 and T10 levels
Upper abdominal muscles (rectus abdominis) are intact at the top of the abdomen but weak at the lower portion, patient is asked to do a sit up – only the upper muscles contract (umbilicus pulled toward the head)

49. Clinical Evaluation Resistive Range of Motion: Flexion:
Patient position – supine with knees flexed and feet flat on table
Stabilization – pelvis
Resistance – applied to the superior sternum as patient lifts the scapulae off the table
Muscles tested – rectus abdominis, internal oblique, external oblique

50. Clinical Evaluation Resisted Range of Motion: Extension:
Patient position – prone with arms interlocked behind the head
Stabilization – lower lumbar region
Resistance – applied to upper thoracic spine as patient lifts head, chest, and arms off table
Muscles tested – iliocostalis lumborum, iliocostalis thoracis, longissimus thoracis, spinalis thoracis, semispinalis thoracis, rotators, latissimus dorsi

51. Clinical Evaluation Resisted Range of Motion: Rotation:
Patient position – supine (hands interlocked behind head)
Stabilization – opposite ASIS
Resistance – anterior aspect of shoulder as it is rotated off the table
Muscles tested – internal oblique, external oblique (opposite side), rotators, multifidi