History and Physical Examination of the Aging Spine

Published on 11/04/2015 by admin

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5 History and Physical Examination of the Aging Spine

Courtney W. Brown, Lonnie E. Loutzenhiser

KEY POINTS

• Problems affecting the aging spine are a multifactorial degenerative process affecting both the soft tissues and bony structures.
• These degenerative processes affect global balance, both sagittal and coronal, and produce neurological findings.
• Any physical findings must correlate with radiographic studies.
• Past history of surgery will influence the patient’s findings.
• Some apparent spinal problems may represent other pathology.

Introduction

With the increasing longevity in our society, the aging spine has become a ubiquitous problem. Natural physiological aging affects both soft tissue and bony structures, leading to the degenerative process in the spine. Each individual patient’s spinal problem has to be correlated and related to that individual’s physiological history, which includes genetics; familial, environmental, and/or occupational problems; as well as the multiple comorbidities with which all of us must live. Perhaps it would be best to outline these various areas of influence to better understand how our histories affect our aging spines.

Past Medical History

Congenital/Familial/Genetic

Abnormal skeletal spine development may occur on a congenital, familial, or genetic basis. This may include various combinations of failure of formation or segmentation of the vertebrae leading to such problems as hemivertebrae, congenital fusions (Klippel-Feil), and congenital scoliosis. These abnormalities may lead to an abnormal stress and wear and tear to relatively normal adjacent levels of the spine, thus having a detrimental effect on these levels through ligamentous and disc degeneration. This may lead to a progressively painful or unstable spine.

Adolescent idiopathic scoliosis, which appears to be genetic in origin, has a totally different influence on the spine as we mature, and can range from a stable balanced spine to a progressive curve with neurological compression and/or global spinal imbalance. Usually, this develops as a slow, progressive vertebral body subluxation secondary to the disc degeneration in the scoliotic levels. This may not occur until later years and at that time, become symptomatic. Aside from spinal pain, as a lumbar curve increases, patients may complain of the rib cage sliding against the pelvis as they become shorter.

Occupational/Environmental/Psychological

A patient’s occupation has a significant impact on the speed and severity of degenerative problems that occur in the adult spine. Certainly, a day laborer who performs loaded twisting of the spine, thus creating annular shearing, is much more likely to have traumatic breakdown of the discs and ligamentous structures than someone with a sedentary occupation. Additionally, smoking decreases the blood supply and nutrition to the vertebral endplates and the intervertebral discs, therefore negatively affecting their healing capabilities. Psychological stress can negatively affect a spine problem and potentiate the pain response to the degeneration. Thus, the patient’s pain threshold and psychological instability may produce increased symptoms through the combination of chronic pain, secondary gain, and subsequent depression. If the symptoms persist, symptom magnification may be a dominant factor. Thus, the physical disease of the spine may be overtaken by the patient’s psyche. The possibility of alcohol abuse and malnutrition also needs to be considered.

Comorbidities

Comorbidities, such as diabetes mellitus, cardiovascular disease, or renal disease, can produce neuropathic pain or neurological deficits. These may be extremely difficult to treat, either nonoperatively or operatively. Uncontrolled diabetes mellitus is well known to produce peripheral neuropathy leading to denervation, as well as pain. Cardiovascular disease, such as an aortic aneurysm or peripheral vascular disease, may cause vascular claudication mimicking spinal pathology. Additionally, patients may have a neurological disorder, such as Charcot-Marie-Tooth disease, that may affect the extremities as well as bowel and bladder function. Pulmonary pathology, such as a Pancoast tumor, may mimic the findings in patients with neck symptoms.

History

Origin of Pain

Pain can be described in multiple ways. The first should be the location and quality, as well as the severity of the pain. The pain must be described in terms of sharpness, dullness, burning, numbness, or throbbing. Is the pain intermittent or constant? Is it alternating in severity? The exacerbating or relieving factors should be noted. Is the pain improving or is it progressively getting worse? The pain may become better or worse with positioning. If worse, the etiology may be tumor or infection. Is the pain associated with any neurological symptoms? Any history of previous spinal procedures, as well as the result of those procedures, is crucially important to note and understand, as there may be some component of permanent damage as a result. The rating of pain from 1 to 10 may be misleading as patients who are repetitively questioned to quantify may become overly conditioned and magnify their response.

Neurological History

History of weakness, falls, gait abnormalities, difficulty with fine motor movement, bowel or bladder dysfunction, and/or sexual dysfunction are all potential signs of myelopathy. This should be obtained in the initial history, which should also include questions about grip strength, dropping items such as coffee cups, or burning the fingers. Upper extremity weakness or pain needs to be noted, along with any associated radicular symptoms into the arms or legs.

Past Surgical History

Any prior surgical history is important, as it may influence the spine. However, most important is the history of any prior spine procedures, their cause, what the procedure was, and what the results of the intervention were. Residual problems following the surgery become extremely important to document, and having copies of the medical record, including the operative notes, can be extremely important.

Physical Examination

Physical examination should incorporate the patient’s stature, habitus, ability to ambulate with or without assistive devices, and quality of gait, as well as the neurological status.

Global Balance

This should include visible appreciation and palpation of a patient’s spine, evaluating it for local or global kyphosis or hyperlordosis, whether it be in the cervical, thoracic, lumbar, or lumbosacral regions. Sagittal balance should be clinically appreciated and measured with a plumb bob. Positive sagittal balance is when the patient’s head and neck are forward of his or her sacrum. Negative sagittal balance is when the head and neck are posterior to the sacrum. Coronal imbalance is a left or right deviation of the plumb bob from the C7 spinous process to the gluteal cleft.

Gait

A patient’s gait should be observed when walking outside the examining room. Patients who walk with a wide-based gait may have spinal stenosis. However, if they also walk with a positive sagittal balance (leaning forward), this can also be global imbalance secondary to previous spinal surgery, degenerative spondylolisthesis, spinal stenosis, or a preexisting spinal deformity. When walking, the patient’s foot and knee position must be observed. If the legs are externally rotated, patients will commonly be out of global balance, and externally rotating the extremity or flexing the knees will allow them to stand more erect. If this occurs, the important part of evaluation is that of having the patient stand with feet in neutral position, knees straightened to normal position, and then observing their overall global posture. Commonly, these patients will suddenly lean into increased positive sagittal balance. Long x-rays, both AP and lateral, should be obtained with the lower extremities in this corrected position.

Neurological

Neurological evaluation should include sensory and motor exams, as well as reflexes, of both the upper and lower extremities. Abdominal sensation and reflexes are also extremely important. Sensation, including light touch, pinprick, pressure, and proprioception, must be evaluated throughout the whole body. Individual muscle groups need to be examined for muscle strength, atrophy, or focal or global weakness. Dr. Stanley Hoppenfeld’s book on orthopedic neuroanatomy is by far the best for quick visual understanding. His simplifying concept for individual extremity nerve evaluation is that the area of sensation and the underlying muscle and reflex are commonly innervated by the same nerve.

Specific Cervical Neurological Levels

C5 Neurological Findings

The motor exam of the C5 nerve root is best examined with the deltoid muscle, which is almost purely innervated by C5 (axillary nerve). The biceps can also be tested but is also innervated by a component of the C6 root.

The sensory distribution of the C5 nerve root is best tested over the deltoid muscle on the lateral aspect of the arm (axillary nerve).

The biceps reflex is the best test to assess C5 function. However, this also has a component of C6 as well.

C6 Neurological Findings

There is no pure motor exam of the C6 nerve root, as there is cross innervation by the C5 and C7 nerve roots. The best muscles to test for evaluating the C6 nerve root are the biceps (also innervated by C5 via the musculocutaneous nerve) and the wrist extensors (extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) innervated by C6 nerve and the extensor carpi ulnaris (ECU) innervated by C7, all via the radial nerve).

The sensory distribution of the C6 nerve root is best assessed over the lateral forearm, thumb, index finger, and radial half of the long finger (musculocutaneous nerve).

The reflex exam of the C6 nerve root can best be assessed with the brachial radialis reflex (purely C6) or with the biceps reflex (C5 component also).

C7 Neurological Findings

There are multiple muscle groups used to test the function of the C7 nerve root. The triceps is purely innervated by the C7 root via the radial nerve. There are two major muscles in the wrist flexor group, the FCR and flexor carpi ulnaris (FCU). The flexor carpi radialis (FCR) is innervated by C7 via the median nerve and is the stronger of the two. The FCU is innervated by the C8 nerve via the ulnar nerve. Finger extensors are primarily innervated by the C7 nerve root. However, there is a component of C8 innervation also.

The most common area of C7 sensory innervation is the long finger. However, there can be some component of the C6 and C8 crossover.

The reflex exam of the C7 nerve root can be assessed with the triceps reflex.

C8 Neurological Findings

C8 motor function is assessed by testing the strength of the finger flexors. There are two finger flexors, the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP). The FDS and the radial half of the FDP are innervated by the median nerve, while the ulnar half of the FDP is innervated by the ulnar nerve.

The best anatomical areas to assess sensory function of the C8 nerve root are the ulnar aspect of the forearm and the ring and small fingers.

There is no C8 reflex exam.

T1 Neurological Findings

The motor function of the T1 nerve is best tested with the ring abductors (dorsal, interosseous, and abductor digiti quinti). The sensory area of the T1 nerve root is over the ulnar aspect of the proximal forearm and distal arm.

There is no deep tendon reflex to assess the T1 nerve root.

Thoracic and Abdominal Neurological Findings

Thoracic neurological findings are primarily sensory and will correspond to an intercostal space. This may indicate a thoracic disc herniation. There are no reflexes for these sensory thoracic nerves.

Abdominal musculature contraction, sensation, and reflexes are evaluated by partial sit-ups, watching for a proximal or distal shift of the umbilicus. This shift may indicate intracanal pathology.

T12 to L3 Neurological Findings

The motor exam of the T12 to L3 nerve roots is best examined with the iliopsoas muscle by testing hip flexion in a seated position.

The sensory distribution of the L1 nerve root is best tested just over and distal to the inguinal ligament anterior on the proximal thigh, the L2 obliquely just distal to L1 on the anterior mid thigh, and the L3 obliquely over the distal anterior thigh and patella.

There is no testable reflex for the T12 to L3 nerve roots.

L2 to L4 Neurological Findings

The motor exam of the L2 to L4 nerve roots is best examined with the quadriceps muscle group and the hip adductor muscle group. The quadriceps muscle group, which is innervated by L2 to L4 nerve roots (femoral nerve), is tested with resisted knee extension in a sitting position, while the hip adductor group, also innervated by the L2 to L4 nerve groups, is tested with resisted hip adduction from an abducted position, either sitting or supine. The sensory distribution of the L2 and L3 nerve roots has been described above, and the sensory distribution and reflex exam of L4 will be described below.

L4 Neurological Findings

The motor exam of the L4 nerve root is best examined with the tibialis anterior muscle, which is most purely innervated by L4 (deep peroneal nerve) and by resisted ankle dorsiflexion and inversion.

The sensory distribution of the L4 nerve root is best tested over the anteromedial lower leg.

The patellar reflex is the best test to assess L4 function. However, it has a component of L2 and L3 as well.

L5 Neurological Findings

The motor exam of the L5 nerve root can be assessed with multiple muscle groups, including the extensor hallucis longus (EHL), the extensor digitorum longus (EDL), and the extensor digitorum brevis (EDB) – all innervated by the deep peroneal nerve – and the gluteus medius (superior gluteal nerve). The EHL is tested by resisted dorsiflexion of the great toe, while the EDL and the EDB are tested by resisted dorsiflexion of the remaining toes. The gluteus medius is tested by resisted abduction of the hip while lying in a lateral position.

The sensory distribution of the L5 nerve root is best tested over the lateral leg and the dorsal foot, most specifically the first dorsal web space on the foot.

The posterior tibialis reflex is the only way to test L5 reflex function. However, it is hard to elicit.

S1 Neurological Findings

The motor exam of the S1 nerve root can be examined by the peroneus longus and brevis muscles (superficial peroneal nerve), the gastrocnemius muscle complex (tibial nerve), and the gluteus maximus (inferior gluteal nerve). The peronei are tested by resisted foot eversion in plantar flexion. The gastrocsoleus complex is tested with ankle plantar flexion. However, it is so strong that manual muscle testing is hard to perform. The best way to assess ankle plantar flexion is by asking the patient to toe walk and assess the toe walk, watching for weakness. The gluteus maximus is best tested with resisted hip extension in the prone position.

Sensory distribution of the S1 nerve root is best tested over the lateral and plantar aspect of the foot.

The Achilles reflex is the best test to assess S1 nerve root function.

S2-4 Neurological Findings

The motor exam of the S2-4 nerve roots is difficult as the motor supply of the S2-4 nerve roots supply the bladder and the intrinsic muscles of the foot. Therefore, any toe deformities should be appreciated.

The sensory distribution of the S2-4 nerve roots supplies the anal sphincter.

Vascular

The patient history and physical evaluation are extremely important in determining whether or not the patient may have vascular claudication or neurogenic claudication. Aortic aneurysm can simulate low back pain and is best appreciated by abdominal palpation with the hips and knees flexed, relaxing the abdominal muscles. Peripheral vascular disease can mimic neurological claudication. However, this should be eliminated by palpation of peripheral pulses and checking for hair distribution or stasis dermatitis.

Summary

The following will be usual physical findings in multiple spinal diagnoses but must be correlated to their imaging studies:

1. Spinal stenosis, central or foraminal

A. Loss of global balance
B. Neurogenic claudication (exam may be normal or have focal deficits)
C. Progressive wide-based gait

2. Herniated nucleus pulposus

A. Cervical: radicular and/or myelopathic symptoms
B. Thoracic: radicular and/or myelopathic symptoms
C. Lumbar: radicular and/or motor and/or cauda equina symptoms

3. Degenerative disc disease/degenerative spondylolisthesis

A. Cervical: radicular/local pain
B. Thoracic: radicular/local pain

4. Spondylolisthesis

A. Stance
B. Hamstrings
C. Increased lumbar lordosis
D. Neurological symptoms can be static or dynamic.

5. Adolescent idiopathic scoliosis/de novo scoliosis

A. Global imbalance, both sagittal and coronal
B. Rotational imbalance
C. Rib hump and lumbar prominence.
D. Leg length discrepancy/pelvic tilt/sacral obliquity

6. Osteoporotic vertebral body fractures

A. Local tenderness
B. Percussive local pain
C. Kyphosis/sagittal imbalance
D. Neurological deficit: radicular or myelopathic

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