LCCW Spinal Orthopedic Examination - Midterm

What ortho-neuro tests indicate possible costoclavicular syndrome?

-Costoclavicular test -Eden's test

What are the findings and significance of the shoulder depression test?

-Creation or aggravation of pain & paresthesia in the upper extremity, especially in a dermatomal distribution, suggests *nerve root dural sleeve adhesions*. -More commonly, neck and shoulder pain is created or aggravated by this test, when *muscle spasm, strain, or ligament sprain* is present. -Depression of the shoulder may cause depression of the clavicle and narrowing of the costoclavicular space causing upper extremity pain if *costoclavicular syndrome* is present.

What are the exam findings and indications for the cervical compression test?

-Creation or exacerbation of local cervical spine pain suggests *joint involvement* (subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder, or arm, and may be present due to sclerogenic referral. -Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy* (which can result from disc herniation or IVF stenosis).

What are the exam findings and significance for the cervical distraction test?

-Decreased *local pain* suggests joint involvement (subluxation, DJD). -Decreased *pain, tingling, & numbness in the upper extremity* suggests cervical radiculopathy (due to IVF stenosis or IVD P/P). -*Discomfort or pain may be produced by this procedure as a result of soft tissue injury*.

What are the variations of the cervical compression test?

-Lateral flexion (Jackson's test). -Flexion -Extension -Rotation

With normal cervical flexion, the chin should approach within _________ of the chest.

2 fingers breaths.

With normal cervical lateral flexion, the head moves approximately ________ to the shoulder.

Half way

What is the significance of a positive Brudzinski sign?

Meningitis

What is the mechanism of the cervical compression test?

The downward pressure compresses the facets, vertebral bodies, disc, and narrows the IVF.

What is the Spurling test?

The examiner places one hand on top of the patient's head and delivers a vertical blow to the top of the patient's head with the other hand.

What is Rust's sign?

The patient presents with both hands supporting or "cradling" the cervical spine, or the patient supports or "cradles" the cervical spine when rising from a supine position. (BPUS = 3.5)

What follow-up tests should be done with a positive Bakody's sign?

-*Orthopedic tests for cervical radiculopathy.* -Cervical compression test and variations. -Cervical distraction test. -Intrathecal pressure tests (Valsalva, etc.) -*Evaluation of cervical spinal nerve function (sensory, motor, reflex).* -Add obliques to routine cervical x-ray series; consider advanced imaging.

How can multi-segmental ROM examinations be performed?

-Actively first, with the patient performing the movement. -Passively, with the doctor bringing the region through the ROM.

What orthopedic tests may help identify cervical rib syndrome?

-Adson's test -Modified Adson's test

What orthopedic tests may help identify scalenus anticus syndrome?

-Adson's test -Modified Adson's test

What ortho-neuro tests indicate possible cervical rib syndrome?

-Adson's test -Modified Adson't test

What ortho-neuro tests indicate possible scalenus anticus syndrome?

-Adson's test -Modified Adson't test

What is Bakody's sign? Aka?

-Aka shoulder abduction relief sign. -The patient presents with the palm of the affected upper extremity (P/T/N radicular complaint) on top of their head. The patient states that this position lessens their upper extremity pain/paresthesia complaints.

What is the role of auscultation in an ortho-neuro examination?

-Assessment of blood vessels for bruits. -Assessment of heart, lungs, and abdomen to help rule out visceral referred pain.

What other conditions may produce positive findings with percussion?

-Bone infection (osteomyelitis). -Bone tumor -Nuchal or supraspinous ligament sprain.

What tests indicate possible meningeal irritation?

-Brudzinski sign -Kernig test

What follow-up tests should be performed following a positive Kernig test?

-Brudzinski's test. -Check temperature. -Emergency referral (lumbar puncture/CSF study, antibiotic therapy).

What ortho-neuro tests indicate possible IVF stenosis (with radiculopathy)?

-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test.

What ortho-neuro tests indicate possible joint involvement (facet, degeneration) without radiculopathy?

-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test.

What ortho-neuro tests indicate possible IVD syndrome (with radiculopathy)?

-Cervical compression test and variations (lateral flexion/Jackson's, flexion, extension, rotation, modified Spurling). -Cervical distraction test. -Foraminal compression test *in flexion*. -Shoulder abduction relief sign (Bakody's). -Intrathecal pressure tests (*Valsalva, Naffzigger*).

What tests indicate possible soft tissue trauma?

-Cervical distraction test. -Shoulder depression test. -Other tests that cause stretching of soft tissues. -*O'Donahue's test* (differentiates strain vs sprain).

What are the findings/significance of the Soto-Hall test?

-Cervical joint disorder (subluxation, DJD, trauma). -Posterior cervical muscle spasm or strain. -Posterior cervical ligament sprain. -Fracture of the vertebral bodies (compression) or spinous process. -If cervical myelopathy is present, pain may radiate down the spine and into the upper or lower extemities (see Lhermitte's sign). -If meningitis is present, the hips and knees may flex (see Brudzinski's sign).

Thoracic outlet syndrome (TOS) includes what syndromes?

-Cervical rib syndrome. -Scalenus anticus syndrome. -Costoclavicular syndrome. -Pectoralis minor syndrome (hyperabduction syndrome).

What follow-up tests should be performed if there is a positive Brudzinski sign?

-Check temperature. -Kernig's test -Emergency referral (Lumbar puncture/CSF study, antibiotic therapy).

What are the findings and significance of the Naffzigger test?

-Creation or aggravation of *upper extremity pain & paresthesia suggests spinal nerve compression by a space-occupying mass* (disc protrusion, tumor, osteophyte).

What are the exam findings for a modified Spurling's test?

-Creation or exacerbation of *local cervical spine pain* suggests joint involvement (subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral. -Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy*.

What are the Variosus intermittent claudication tests?

-Elevated Arm Stress Test (EAST). -Intermittent claudication test. -Roos test

What are the contraindications for the Naffzigger test?

-Geriatric patients. -Caution should be used when testing patients with suspected atherosclerosis. (Lightheadedness, dizziness, or syncope may occur).

What are the positive findings and significance of the Kernig test?

-Inability to extent the leg due to pain is a positive finding. -Flexion of the opposite hip and knee may occur. -Suggests possible *meningitis*. -Correlate the exam findings with other signs and symptoms of meningitis on the history and exam.

What is the mechanism associated with the Soto-Hall test?

-It compresses the vertebral bodies anteriorly. -It posteriorly tractions the nuchal ligament and pulls on the spinous processes. Posterior musculature is stretched.

What are the possible findings for the maximum cervical compression maneuver?

-Local cervical spine pain suggests *joint involvement* (subluxation, DJD, trauma, etc). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral. -Pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests *cervical radiculopathy*.

What procedures should follow a positive maximum cervical compression maneuver?

-Modified Spurling test -Cerical distraction test -Valsalva maneuver -*Neurologic exam of the sensory, motor, and reflex functions of the cervical spinal nerves.*

What may cause a positive Lhermitte's sign?

-Multiple Sclerosis -Myelopathy associated with cervical spondylosis and spinal canal stenosis. -Central disc protrusion/prolapse. -Tumor

What tests should be administered following a positive Lhermitte's sign?

-Neurologic exam. -MRI -Electrodiagnostic tests.

What additional tests should follow a positive Valsalva maneuver?

-Orthopedic exams (Naffzigger/jugular compression test, cervical compression tests, cervical distraction test). -Neurologic exam of spinal nerve functions. -Diagnostic imaging.

What other tests should be done following a positive cervical distraction test?

-Orthopedic exams (cervical compression tests, shoulder abduction relief sign, intrathecal pressure tests/ Valsalva). -*Examination of the neurologic functions of the cervical spinal nerves (senrosy, motor, reflex)*.

What procedures should follow a positive Modified Spurling test?

-Orthopedic exams (other compression tests, cervical distraction test, valsalva meneuver). -*Neurologic exam of the sensory, motor, and reflex functions of the cervical spinal nerves.*

What other tests should be administered following a positive Naffzigger test?

-Other cervical orthopedic exams for radiculopathy. -Neurologic assessment of spinal nerve function. -Diagnostic imaging.

What are the findings and significance of the Valsalva maneuver?

-Production or exacerbation of radiation into the upper extremity, especially in a dermatomal pattern. -A positive finding suggests that a radiculopathy due to compression by a space occupying mass (disc protrusion/prolapse, tumor, osteophytes) is present.

How should Bakody's sign be reported?

-Relief of arm pain/paresthesia with the arm abducted suggests (or indicates) cervical radiculopathy. -Cervical radiculopathy is suggested (indicated) by a Shoulder Abduction Relief sign on the right.

What is the rationale/mechanism of the O'Donahue test?

-Resisted motion primarily stresses muscle and tendon (contractile elements). Muscles hurt when you contract them if they are injured. -Passive motion (stretching) primarily stresses ligaments (non-contractile elements). Ligaments hurt when stretched if they are injured. -Combination strain-sprain injuries will result in pain on both resisted contraction and passive stretching. -Since strained muscles may also hurt during passive stretching, strains may present with pain during resisted contraction and passive stretching.

What tests indicate possible fracture/dislocation?

-Rust sign -Soto-Hall test

What are the potential sites of compression of structures involved in TOS?

-Scalene triangle (between the anterior and middle scalene muscles, and the first rib). -Costoclavicular space (between the first rib and clavicle). -Pectoralis minor (under the pectoralis minor or tendon).

What are the 4 subgroups of TOS that are commonly ientified?

-Scalenus anticus syndrome -Cervical rib syndrome -Costoclavicular syndrome -Pectoralis minor syndrome (aka hyperabduction syndrome).

What are abnormal findings for percussion?

-Significant local pain. -Radicular pain.

When visually estimating cervical ROM, what should the doctor do?

-The measurement should be recorded in 5 degree increments. -Look for reference points from neutral that suggest full ROM. -Look for symmetry of motion.

What is Lhermitte's sign?

-This sign *suggests myelopathy* (spinal cord disorder) of the cervical spinal cord. -With the patient seated, passively flex the patient's head toward their chest.

What ortho-neuro tests indicate possible pectoralis minor syndrome?

-Wright's test (hyperabduction test)

What is the significance of Lhermitte's sign?

A positive sign suggests cervical myelopathy. Lhermitte's sign is NOT diagnostic for MS. Some people say that it is pathognomonic. You can have MS without Lhermitte's sign and vice versa.

Before taking measurements with an inclinometer, what should be done?

A warm-up should be performed prior to the measurements, consisting of flexion-extension twice, left & right rotation twice, left & right lateral flexion twice, and one additional flexion & extension.

What is the cervical distraction test?

The main purpose of this test is to see if decreased pressure on cervical spiine structures reduce pain. -With the patient seated, the examiner stands at the side of the patient and places one hand under the patient's chin and the other under the base of the occiput (or one hand on either side of the head without pressing in on ears). With gradually increasing force, lift the patient's heat to remove it's weight from the neck. Hold for 30-60 seconds.

What is cervical rib syndrome?

When a cervical rib (congenital variant, extra rib off C7) causes the compression.

What is scalenus anticus syndrome?

When the scalene muscles are responsible for the compression (spasm, hypertrophy, or congenital variations in tendon attachments).

Can cervical rotation be measured with an inclinometer?

Yes, with the patient supine. A compass may be utilized to measure rotation with the patient seated.

Although most commonly used for low back involvements, the Naffzigger test may also be effective in evaluating the ________ and ________ regions.

Cervical and thoracic.

What is the significance of Bakody's sign?

Cervical radiculopathy (C5-7). -This position relieves traction on the brachial plexus and cervical spinal nerves. -*Exacerbation of arm pain/paresthesia suggests Pectoralis Minor (hyperabduction) syndrome.*

What is costoclavicular syndrome?

Compression in the costoclavicular space.

What orthopedic tests may help identify costoclavicular syndrome?

Costoclavicular test (Eden's test)

How should a true measurement of ROM be taken with an inclinometer?

Each measurement should be performed 3 times and averaged. -If the average is less than or equal to 50 degrees, each of the three consecutive measurements must fall within 5 degrees of the mean. -If the average is greater than 50 degrees, then each of the 3 measurements must fall within 10% of the mean. -The ROM measurements may be repeated up to 6 times to obtain 3 consecutive ROM measurements. -If after 6 measurements there is still inconsistency, the ROM measurements are considered invalid.

Lhermitte's sign should be reported whenever flexion of the neck produces pain radiating down the spine regardless of position.

Ex// During the Soto-Hall or Brudzinski tests.

What is the normal ROM for cervical flexion, extension, lateral flexion, and rotation?

Flexion - 50 Extension - 60 Lat flexion - 40 Rotation - 80

What is Brudzinski sign?

Flexion of the head causes stretching of the dural sac and spinal cord. -With the patient supine, the examiner flexes the patient's head to their chest (without sternal stabilization). -Positive sign is flexion of the hips and knees.

With normal cervical extension, the plane of the face does not become horizontal, however a line between the ________ and the ________ does become parallel to the floor.

Forehead and the tip of the nose.

What are the signs and symptoms of meningitis?

Headache, stiff neck (nuchal rigidity), fever, and elevated temperature.

Lateral flexion with cervical compression narrows what?

Ipsilateral IVF

What is a CROM device and what is its advantage?

It attaches the measurement instruments to the patients head and eliminates a source of examiner error.

Head flexion with compression does what?

It increases loading of the anterior part of the vertebral motor unit (disc, vertebral body). Disc compression anteriorly, with possible increased bulging posteriorly, may exacerbate radicular symptoms when disc protrusion/prolapse is present.

Head extension with compression does what?

It increases loading of the posterior aspect of the vertebral motor unit; disc compression will occur posteriorly, and the IVFs will be narrowed. -Radicular symptoms may be exacerbated when IVF stenosis is present. (Radicular symptoms due to disc p/p may be somewhat reduced since the disc may be displaced anteriorly).

How do you differentiate between cervical rib and scalenus anticus syndrome?

It is primarily based on x-ray and the presence or absence of a cervical rib. -Can also attempt to palpate the presence of a cervical rib in the supraclavicular fossa, and palpate for hypertonicity of the scalene muscles.

What is the significance of Rust's sign?

It is seen in marked cervical strain-sprain injuries (especially the anterior compartment). -*This should be considered a sign of cervical instability, and a contraindication to ROM and orthopedic biomechanical stress exams until instability due to fracture, dislocation, or severe sprain is ruled out by x-rays.*

What is thoracic outlet syndrome (TOS)?

It refers to a group of disorders involving compression of the neural (brachial plexus) and/or vascular (subclavian-axillary artery and axillary-subclavian vein) structures in the thoracic outlet.

When should instrumentation be used during an exam?

It should always be used for medico-legal reasons such as Workman's comp, disability evaluation, and personal injury cases.

What is the Naffzigger test (jugular compression test)?

Like the Valsalva Maneuver, this test increases intrathecal pressure and helps identify space-occupying lesions causing radiculopathy. It is much faster and easier to use the Valsalva maneuver. -With the patient seated or supine, the examiner compresses the jugular veins for 30-45 seconds. -Compressing the jugular veins backs up venous drainage from the head. The backup in the dural venous sinuses may lead to decreased absorption of CSF, resulting in increased CSF pressure.

What is IVD syndrome?

Percussion may create or aggravate radicular pain.

How can a tuning fork be used to assess suspected fracture?

Placing a *128 Hz* turing fork on the superficial body process produces significant local pain if there si a fracture. -A negative finding *does not* rule out fracture or the need for radiographic studies.

What is a positive Lhermitte's sign?

Sharp pain down the spine and into the upper or lower extremities.

What ortho-neuro tests indicate possible adhesions?

Shoulder depression test and other tests that may cause stretching of the nerve roots.

What is the significance of percussion?

Significant local pain in a traumatized area is suggestive of fracture.

What are inclinometers?

The are instruments which measure angular displacement relative to gravity.

What is meningitis?

A serious, potentially deadly disease. Emergency medical attention is necessary.

Normal ROM varies with what?

Age and gender.

What test is for vascular patency?

Allen's test

With normal cervical rotation, the chin ________ the ________, but does not quite become parallel to it.

Approximates the shoulder.

What is the Dual inclinometer measurement of cervical ROM?

The use of 2 inclinometers, one on the head and the other at T1, helps to eliminate any contribution of upper thoracic movement to the total measurement, thus potentially providing a more accurate measurement of the cervical motion.

What is the Spurling test and modified Spurling test?

These are compression tests with the head in the maximal cervical compression maneuver position. The modified version is preferred because a more comtrolled force is utilized.

What is the Valsalva maneuver?

This exam *increases intrathecal (CSF) pressure* and helps to identify radiculopathy caused by a space-occupying lesion. -With the patient seated, the examiner instructs the patient to take a deep breath, hold it, and "bear down" as if trying to move their bowels. -Be cautious, because the patient may become lightheaded or pass out during, or shortly after this test.

What is the maximum cervical compression maneuver?

This is an active motion test utilizing a combination of 2 head positions to narrow the IVF. With the patient seated, the examiner instructs the patient to rotate and extend their head (compression is not applied).

What is the O'Donahue test?

This procedure attempts to differentiate strain (muscle and/or tendon injury) from sprain (ligamentous injury). -With the patient seated, have the patient perform active cervical motion against your resistance, or apply resistance sufficient to prevent motion such that an isometric contraction occurs. Then take the cervical spine through passive ROM.

What is Kernig's test?

This procedure tractions the sciatic nerve, lumbar spinal nerves, and ultimately the meninges. -With the patient supine, the hip and knee are flexed to 90 degrees. The examiner then attempts to extend the leg at the knee.

What is Soto-Hall test?

This test is often noted as a test for fracture, however pain and restriction is more commonly due to cervical joint disorder or posterior soft tissue involvement. -If fracture is suspected, the radiographic exam should be done prior to ROM and orthopedic exams. -With the patient supine, the examiner places their caudal hand on the patient's sternum and exerts slight pressure to prevent the thoracic spne from flexing during the test. The examiner's cephalad hand is placed under the occiput and passively flexes the patient's head to their chest.

What is the shoulder depression test?

This test is primarily known as a test for nerve root dural sleeve adhesions, however, it also causes stretching of muscles, and ligaments. -With the patient seated, the examiner stands behind the patient and laterally flexes the patient's head away and then depresses the shoulder. -This procedure causes stretching of muscles/tendons, ligaments, and spinal nerves on the side of shoulder depression.

What else may cause pain and restriction upon leg extension (aside from meningitis)?

Tight hamstrings, lumbar radiculopathy, sciatic neuropathy, etc.

What is the primary purpose of percussion of osseous structures?

To investigate suspected fractures.

Why is thorax and abdomen percussion necessary?

To rule out visceral referred pain in order to DDX from back pain.

What is the purpose of the cervical compression test and its variations?

To see if increased pressure on the cervical spine structures creates or exacerbates pain.