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.