Adapted from Hefford C: McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference, Man Ther 13(1):75–81, 2008.

1. Posture syndrome. Pain arises as a result of mechanical deformation of normal soft tissues from prolonged end-range loading of periarticular structures.

2. Dysfunction syndrome. Pain occurs as a result of mechanical deformation of structurally impaired tissues (scarred, adhered, or adaptively shortened tissue).

3. Derangement syndrome. Pain occurs as a result of a disturbance in the normal resting position of the affected joint surfaces.

4. Other. Patient exhibits signs and symptoms of other known abnormality (i.e., spinal stenosis, hip disorders, sacroiliac disorders, low back pain in pregnancy, zygapophyseal disorders, spondylolysis and spondylolisthesis, and postsurgical problems).

ORTHOPEDIC GAMUT 7-3 THORACIC SPINE

Stabilizing influences for the thoracic spine include the following:

• The first element is the vertebral articular process. The interlocking arrangement of the thoracic facets prevents anterior displacement of the vertebra and forms the imbrication of the thoracic spine.

• The second primary stabilizing influence of the thoracic spine is the vertebral body. At the posterior of the vertebral bodies, the height of the body is greater than in the anterior. This circumstance contributes to the thoracic spine kyphosis.

• The third stabilizing influence is the structure of the ribs and their attachments to the spine. The ribs help stiffen the thoracic spine.

• The fourth primary stabilizing influence for the thoracic spine is the structure of the intervertebral disc. The thoracic spine intervertebral discs are more narrow and thin than in the cervical or lumbar spines. They are also less elastic than all the other disc tissues of the spine.

ORTHOPEDIC GAMUT 7-4 THORACOLUMBAR SPINE

To assess range of motion of the thoracolumbar spine, the patient is directed to do the following:

1. Slowly bend forward at the waist and try to touch the toes (while observed for scoliosis) (Figs. 7-1 and 7-2).

2. Bend back as far as possible (hyperextending the spine) (Fig. 7-3).

3. Bend to the right and left side as far as possible (lateral bending with the pelvis stabilized) (Fig. 7-4).

4. Turn to the right and left in a circular motion (with the pelvis stabilized) (Figs. 7-5 and 7-6).

FIG. 7-1 Flexion range of motion in the thoracic spine is 20 to 45 degrees.

FIG. 7-2 For testing flexion with an inclinometer, the patient is seated or standing. (A). The thoracic spine is flexed forward so as not to involve lumbar spine motion (B). Both instrument readings are recorded. The T12 value is subtracted from the T1 value to arrive at the thoracic flexion angle.

FIG. 7-3 Extension in the thoracic spine is normally 25 to 35 degrees.

FIG. 7-4 Lateral flexion is approximately 20 to 40 degrees to the right and left.

FIG. 7-5 Rotation in the thoracic spine is approximately 35 to 50 degrees.

FIG. 7-6 When an inclinometer is used to assess thoracic spinal rotation, the patient is standing. The patient is flexed forward. The T12 measurement is subtracted from the T1 measurement to arrive at the thoracic rotation angle.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

In addition to te bony and discal stabilizing influences of the thoracic spine are muscles that support the spinal column. The thoracic spinal column serves as the attachment for many of the muscles of the trunk, shoulder, and arm.

During the trunk extension test, the latissimus dorsi, quadratus lumborum, and trapezius assist back extensors. The head and neck extensor muscles and the hip extensors should be tested before the back extensors are tested (Fig. 7-7).

FIG. 7-7 The patient is prone. The patient then attempts trunk extension.

ESSENTIAL IMAGING

Although plain-film radiographs are generally unreliable in the early detection and assessment of osteoporosis, plain-film findings of osteoporosis can be a helpful adjunct to the diagnosis. The trabecular bone becomes sparse, resulting in overall reduction in bone density. Nontraumatic compression deformities are a sure sign that bone density is compromised.

ORTHOPEDIC GAMUT 7-5 VERTEBRAL COMPRESSION DEFORMITIES

Compression deformities of vertebrae may take several shapes:

1. An isolated central end-plate impression may be present.

2. Biconcave end-plate deformities may be present.

3. The segment may lose anterior vertebral body height with maintenance of the end-plate integrity.

4. The segment may demonstrate loss of anterior and posterior vertebral body height.

5. Fractures of the ribs are quite common.

ADAMS POSITIONS

Assessment for Pathologic or Structural Scoliosis

Comment

The spinal column centers the mass of the torso and head in a line along the vertical axis that falls through the pelvis. Disturbances of the spine, such as the curvatures associated with scoliosis, may significantly alter the normal balance and coordination of the spine (Table 7-3).

TABLE 7-3 THORACIC SPINE SYNDROMES

Scoliosis is also classified as either structural or nonstructural. Structural curves are fixed and nonflexible and fail to correct with side bending. Nonstructural curves, on the other hand, are flexible and readily correct with side bending. The Lenke Classification System helps examiners develop a more complete picture of the patient’s condition by understanding the scoliosis as multidimensional and considering it from more than one view. The Lenke classification method also gives more detailed shorthand for communicating about scoliosis in professional settings, using a widely understood set of criteria (Table 7-4).

TABLE 7-4 LENKE SCOLIOSIS CLASSIFICATION

The Lenke Classification System is simple, accurate, and easy to reproduce and communicate between health care providers. It relies on measurements taken from standard radiographs (X-rays). In this method, the examiner evaluates X-rays of the patient from the front, the side, and in bending positions. Each scoliosis curve is then classified in three steps by the region of the spine, the degree or angle of the curve, and the relationship of the side-to-side curve to the sagittal plane. For example, many scoliosis curves affect the presence or absence of kyphosis, which is the outward or convex curve normally found in the upper back. In addition, each aspect of the curve is evaluated for its relative stiffness or flexibility.

From Dr. Lawrence Lenke, Washington University School of Medicine, St. Louis, Missouri. Available at: www.spinal-deformity-surgeon.com.

ORTHOPEDIC GAMUT 7-6 SCOLIOSIS

Scoliosis predictive indexing:

1. Curves less than 20 degrees will improve spontaneously more than 50% of the time.

2. No accurate method is available to help predict which curves will improve or worsen.

3. In curves of less than 30 degrees, 20% will progress.

4. Progression is more common in young children, at the beginning of their growth spurt.

5. The larger the curve at detection, the greater the chance of progression.

6. Curves in female patients and double curves in male or female patients are more likely to progress.

7. Scoliosis is more common in female patients than in male patients (idiopathic); 9:1 ratio.

PROCEDURE

• If the patient has an S or C scoliosis, the curvature may straighten when the spine flexes forward.

• A curvature that does straighten is a negative sign, indicating evidence of functional scoliosis.

• A positive sign occurs when the scoliosis does not improve after flexing forward.

• A positive sign is evidence of pathologic or structural scoliosis, and it indicates altered morphologic abnormality, pathologic condition, trauma, and subluxation.

• A posterior Adams position requires the examiner to be behind the patient (Fig. 7-8).

• An anterior Adams position requires the examiner to be in front of the patient.

FIG. 7-8

CLINICAL PEARL

When the scoliotic curvature disappears in the Adams position, the curves are mild to moderate, or less than 25 degrees. These curves have more of a functional component than a structural component and are amenable to conservative management.

AMOSS SIGN

Assessment for Ankylosing Spondylitis, Severe Sprain, or Intervertebral Disc Syndrome

Comment

Ankylosing spondylitis (AS), an ascending disease, affects the thoracic region after the lumbar. Patients with this condition experience back pain, but the anterolateral chest pain and the limited chest expansion bother them the most. In some patients, these symptoms may occur rather early in the life of the disease, but they usually become bothersome after 6 years of illness. Chest pain, which usually occurs during inspiration, and limited chest expansion are caused primarily by involvement of costovertebral and manubriosternal joints, as well as the costochondral junctions and the clavicular joints. The girdle-like restriction may cause a sense of anxiety and dyspnea, particularly during exertion. However, respiratory problems are surprisingly uncommon, although restricted ventilatory volumes are detected by pulmonary function studies (Table 7-5). Of course, should concomitant disease result in impaired diaphragmatic breathing, a problem is likely to develop.

TABLE 7-5 MODIFIED NEW YORK CRITERIA FOR ANKYLOSING SPONDYLITIS DIAGNOSIS

Clinical criteria

Low back pain and stiffness for more than 3 months that improves with exercise but is not relieved by rest

Limitation of motion of the lumbar spine both the sagittal and the frontal planes

Limitation of chest expansion relative to normal values corrected for age and sex

Radiological criterion Sacroiliitis grade 2 bilaterally or sacroiliitis grade 3–4 unilaterally

Adapted from Moll JMH: New criteria for the diagnosis of ankylosing spondylitis, Scand J Rheum 16(suppl 65):12-24, 1987.

PROCEDURE

• The recumbent patient places the hands far behind the body and tries to arise from the supine position to the seated position.

• The patient can also be in a side-lying position.

• The examiner should note the patient’s position of comfort and any spinal complaints that the patient presents.

• The patient arises from the side-lying position to a sitting position (Fig. 7-9).

• The sign is present when either action elicits a localized thoracic or thoracolumbar spinal pain.

• The sign suggests ankylosing spondylitis, severe sprain, or intervertebral disc syndrome.

FIG. 7-9

CLINICAL PEARL

The patient sometimes defers to a side-lying posture when trying to stand after lying supine. This action represents Amoss sign. Amoss sign may not produce pain, but it reveals stiffness and lack of mobility and is still useful for detecting chronic spondylitis, which, at the least, requires imaging of the thoracolumbar spine.

ANGHELESCU SIGN

Assessment for Tuberculosis of the Vertebrae or Other Destructive Processes of the Spine

ORTHOPEDIC GAMUT 7-7 SIGNS AND SYMPTOMS OF TUBERCULOUS MENINGITIS

Adapted from Garcia-Monco JC: Central nervous system tuberculosis, Neurol Clin 17(4):737-759, 1999.

• Fever

• Headache

• Meningismus

• Abnormal mental status

• Vomiting

• Malaise-anorexia

• Papilledema

• Cranial-nerve palsies

• Hemiparesis, hemiplegia

• Seizures

• Hydrocephalus (CT scan)

ORTHOPEDIC GAMUT 7-8 PROBLEMS IN CONFIRMING THE CLINICAL SUSPICION OF TUBERCULOSIS MENINGITIS

Adapted from Garcia-Monco JC: Central nervous system tuberculosis, Neurol Clin 17(4):737-759, 1999.

• Approximately 45% of patients will have chest radiographic evidence of past or present tuberculosis, and approximately 50% will have a positive tuberculin test.

• Typical routine cerebrospinal fluid (CSF) profile demonstrates a lymphocyte predominant pleocytosis, a raised protein and a low glucose, tuberculous meningitis can be excluded on the absence of these parameters alone.

• The CSF may be acellular in as many as 3% to 6% of human immunodeficiency virus (HIV)-negative patients. The CFS may be acellular in as many as 16% of HIV-positive patients.

• HIV-negative patients may have a neutrophilic predominance in 20% to 25% of HIV-negative patients.

• The protein level may be normal in approximately 6% of HIV patients, the glucose level may be normal in approximately 25% of HIV-negative patients.

• The protein and glucose figures are increased in HIV-positive patients.

• Smears of the CSF, although diagnostic, are positive in only 5% to 20% of cases.

• Culture, though the gold standard, is positive in approximately 40% of cases. Cultures and may take up to 6 weeks to return a positive result.

PROCEDURE

• Anghelescu sign is used for identifying tuberculosis of the vertebrae or other destructive processes of the spine.

• In the supine position, the patient places weight on the head and heels while lifting the body upward (Fig. 7-10).

• Inability to hyperextend the spine indicates a disease process.

FIG. 7-10

CLINICAL PEARL

When testing for Anghelescu sign, the loss of the ability to achieve a near opisthotonos posture is significant. Although the true opisthotonos posture involves the cervical spine, very few patients normally have enough strength in the neck to accomplish this task.

BEEVOR SIGN

Assessment for Myelopathy Associated with the T10 Spinal Level

ORTHOPEDIC GAMUT 7-9 GUILLAIN-BARRÉ SYNDROME DISABILITY SCORE

Adapted from van Koningsveld R et al: A clinical prognostic scoring system for Guillain-Barre syndrome, Lancet Neurol 6(7):589–594, 2007.

The Guillain-Barré syndrome (GBS) disability score is a widely accepted scoring system to assess the functional status of patients with GBS in which scores range from 0 (normal) to 6 (dead).

• Poor outcome is a GBS disability score at 6 months of 3 or more, which corresponds with the inability to walk 10 m independently.

• Fairly good outcome is defined as a GBS disability score at 6 months of 2 or less.

• The endpoint is at 6 months because most of the recovery process has occurred by this time in select patients who do recover.

• The GBS index:

0 A healthy state

1 Minor symptoms and capable of running

2 Able to walk 10 m or more without assistance but unable to run

3 Able to walk 10 m across an open space with help

4 Bedridden or chair bound

5 Requiring assisted ventilation for at least part of the day

6 Dead

ORTHOPEDIC GAMUT 7-10 MEDICAL RESEARCH COUNCIL SUM SCORE

Adapted from van Koningsveld R et al: A clinical prognostic scoring system for Guillain-Barre syndrome, Lancet Neurol 6(7):589–594, 2007.

1. The Medical Research Council (MRC) sum score is the sum of the scores of six muscle groups, which include shoulder abductors, elbow flexors, wrist extensors, hip flexors, knee extensors, and foot dorsiflexors, bilaterally. Scores range from 60 (normal) to 0 (quadriplegic).

2. The MRC score of an individual muscle group ranges from 0 to 5:

0 No visible contraction

1 Visible contraction without movement of the limb

2 Active movement of the limb, but not against gravity

3 Active movement against gravity over (almost) the full range

4 Active movement against gravity and resistance

5 Normal power

The GBS disability score is probably the easiest to apply in clinical practice, although the MRC sum score might be more accurate. Moreover, a variable measured at 1 week supplies information in an early phase of the disease and therefore might be more helpful in early decision making concerning therapeutic intervention.

PROCEDURE

• Beevor sign, although not an abdominal reflex, is seen during an examination.

• In this test, the recumbent patient lifts the head off the examining table (Fig. 7-11).

• Normally, the upper and lower abdominal muscles contract equally and the umbilicus does not move or drift.

• When the lower abdominal muscles alone are weakened, the umbilicus will be drawn upward by the contraction of the intact upper musculature (Fig. 7-12).

• This effect is associated with a spinal cord lesion at the T10 level.

FIG. 7-11

FIG. 7-12

CLINICAL PEARL

In the presence of prolonged illness followed by lower extremity paresthesia (regardless of how minor), this test needs to be performed. Beevor sign affords an early, noninvasive indicator of the existence of thoracic spinal cord myelopathy.

CHEST EXPANSION TEST

Assessment for Spinal Ankylosis

PROCEDURE

• The chest diameter is measured at the level of the fourth intercostal space.

• The measurement is taken as the patient exhales maximally.

• A second measurement is made as the patient inhales deeply (Fig. 7-13).

• The normal difference between inspiration and expiration is 5.75 to 7.62 cm (1.5 to 3 inches).

FIG. 7-13

CLINICAL PEARL

Chest expansion measurements are sensitive indicators of early involvement of the costovertebral joints in ankylosing spondylitis. The chest expansion test is often positive before the patient realizes a change in chest comfort.

FIRST THORACIC NERVE ROOT TEST

Assessment for First or Second Thoracic Nerve Root Involvement

ORTHOPEDIC GAMUT 7-11 NERVOUS SYSTEM

The four components of the nervous system that refer pain or discomfort follow:

1. The spinal cord

2. The dural sleeve of a nerve root

3. The nerve trunk

4. A peripheral or cutaneous nerve

ORTHOPEDIC GAMUT 7-12 COMMON HISTORICAL AND PHYSICAL FINDINGS IN THORACIC INTERVERTEBRAL DISK HERNIATION

Adapted from Linscott MS, Heyborne R: Thoracic intervertebral disk herniation: a commonly missed diagnosis, J Emerg Med 32(3):235-238, 2007.

Historical findings

• Bowel/bladder involvement

Physical findings

• Weakness—lower extremities

• Localized spine tenderness

• Sensation abnormalities

• Reflex abnormalities

ORTHOPEDIC GAMUT 7-13 PAIN REFERRAL

Pain referral rules are as follows:

1. Pain refers segmentally. A T5 tissue refers pain to the T5 dermatome. Pain can occupy all or any part of the dermatome. If the patient describes symptoms straddling more than one dermatome or if the pain migrates from one dermatome to another, four possibilities arise: (a) The patient is describing a nonorganic pain; (b) the lesion itself is shifting, which often happens with vertebral element displacements; (c) the lesion is spreading, as in metastasis; or (d) the pain stems from a tissue that cannot refer pain segmentally. An exception of importance is the dura mater, which refers pain extra segmentally.

2. Pain refers distally. The source of symptoms is sought locally or proximally.

3. Referred pain does not cross the midline. A T5 left rib will not cause discomfort on the right side of the body. A pain felt centrally must originate from a central structure. Pain that cannot be accounted for by a unilateral structure must be sought centrally. A pain alternating from one side of the body to the other must have a central source. This central source must be able to shift from one side to the other, such as during an intervertebral disc displacement.

4. The extent of pain reference is controlled. The referred pain is controlled by the size of the dermatome and the position in the dermatome of the tissue lesion. A large dermatome permits greater reference than a small one. A lesion in the proximal part of the dermatome refers pain farther than a lesion in the distal part.

5. The more intense the pain, the more the number of cortical cells that will excited. The spread to adjacent cells in the sensory cortex is interpreted as an enlargement of the painful area.

6. The deeper a soft-tissue lesion lies, the larger the reference to be expected. However, bone lesions produce minimal pain radiation.

PROCEDURE

• Pain from stretching the first thoracic nerve root via the ulnar nerve identifies the T1 or T2 roots.

• Disc lesions at either level are rarities and are not accompanied by easily identifiable neurologic signs.

• If weakness is present, the possibility of serious disease should be considered.

• The affected arm is abducted to 90 degrees. The elbow is flexed with the pronated forearm to 90 degrees.

• The patient places the hand behind the neck (Fig. 7-14).

• The ulnar nerve and the T1 nerve root are stretched.

• A positive test is indicated by scapular pain on the ipsilateral side.

FIG. 7-14

CLINICAL PEARL

The first thoracic nerve root stretch indicates nerve root compression. This stretch can also indicate the existence of an inflammation of the lower two branches of the brachial plexus, a nonvascular thoracic outlet syndrome. This diagnosis is further confirmed by Roos test.

FORESTIER BOWSTRING SIGN

Assessment for Ankylosing Spondylitis

ORTHOPEDIC GAMUT 7-14 THORACIC KYPHOSIS

Patients with thoracic kyphosis are classified into the following two groups:

1. Patients in the first group exhibit a major increase in thoracic kyphosis, with an associated loss of lumbar lordosis and a rigid spine. With sufficient extension of the lumbar spine, compensation can be achieved for the thoracic kyphosis, allowing a horizontal gaze and erect posture.

2. Patients in the second group have thoracic kyphotic deformity but maintain a normal or even increased (compensatory) cervical and lumbar lordosis.

PROCEDURE

• The standing patient performs side bending and reveals ipsilateral tightening and contracture of the paraspinal musculature.

• Normally, the contralateral musculature demonstrates tightening (Fig. 7-15).

• The test is significant for ankylosing spondylitis.

FIG. 7-15

CLINICAL PEARL

Although the presence of Forestier bowstring sign suggests spondylitis, this test also indicates strain and intervertebral disc involvement. Any loss of symmetric motion must be examined further.

PASSIVE SCAPULAR APPROXIMATION TEST

Assessment for T1 or T2 Nerve Root Problem

PROCEDURE

• The examiner passively approximates the patient’s scapulae.

• Ipsilateral T1 or T2 nerve root problem is indicated by scapular pain (Fig. 7-16).

FIG. 7-16

RIB MOTION TEST

Assessment for Hypermobile or Hypomobile Costal Structures

PROCEDURE

• As the supine patient inhales and exhales, the anteroposterior movement of the ribs is palpated (Fig. 7-17).

• Restriction in motion is noted.

• Rib abnormalities during exhalation suggest an elevated rib (lowest rib).

• Rib abnormalities during inhalation suggest a depressed rib (uppermost rib).

FIG. 7-17

SCHEPELMANN SIGN

Assessment for Costal and Intercostal Tissue Integrity

Comment

Any fixation or aberrant movement of the costovertebral articulations, or ribs, can have an impact on the synovial joints of the dorsal spine. The examiner rarely finds concomitant loss of joint play at the rib angle and corresponding vertebral motor unit. Experts have suggested that the rib cage may act as a splint to the thoracic spine. This splinting effect may prevent stresses placed directly on the midspine. In addition, it may be one of the reasons that thoracic disc herniations are less common. The fully developed ribs protect the underlying thoracic viscera while simultaneously providing attachment sites for a wide variety of muscles (Table 7-6).

TABLE 7-6 THORACIC CAGE ARCHITECTURE

Region	Tissues
Superiorly	Sternocleidomastoid, sternohyoid, sternothyroid, and anterior, middle, and posterior scalene muscles
Anteriorly	Pectoralis major and minor muscles, mammary glands
Posteriorly	Serratus posterior superior and inferior, and deep back muscles; trapezius, rhomboid minor and major, scapula, and all muscles related to it reset against the thoracic cage
Laterally	Serratus anterior muscles
Inferiorly	Abdominal muscles attaching to thoracic cage (i.e., rectus abdominis, external and internal abdominal oblique, transverses abdominis)