Spine 4 exam!

normal kyphotic convexity

20-40

costochondral junction

rib into cartilage

sternocostal joints

sternum to cartilage

costovertebral joint 

rib to thoracic vertebral body

costotransvere joint

rib to transverse process

what muscle does inhalation?

external intercostals

what muscle does forced expiration?

internal intercostals

thoracolumber flexion

70-85

thoracolumbar extension

45

thoracolumbar lateral flexion

45

thoracolumbar rotation

30-40

thoracic discogenic pain

• Involved structures ; annulus fibrosis, nucleus pulposis, spinal nerve root 

• MOI ; trauma 

• Complaints ; typically asymptomatic and picked up on MRI as incidental finding 

• Neuro ; dermatomes, myotomes, or abdominal reflexes could be affected but difficult to isolate

• Diagnosis ; MRI 

• Treatment ; TE, injection, surgery

thoracic fractures and spinal stability

• MOI ; trauma, axial overload, rapid flexion (seatbelt injury), extreme rotation or sheer

• Complaints ; pain and loss of function 

• ROM ; limited and painful 

• Neuro ; motor, sensory, reflexes can all suffer deficits 

• Dx ; Xray and CT

• Treatment ; thoracolumbosacral orthosis, TE, surgery if unstable

rib fracture

• MOI; direct trauma, repetitive muscle contraction or forceful coughing can cause stress fx 

• Complaints ; localized pain, pain with deep breath, and trunk movement 

• ADLs affected ; breathing, lifting 

• Effects on ROM and strength ; may be decreased due to pain 

• Neurologic exam ; normal 

• Diagnosis ; Xray 

• Treatment ; rest, stabilization, NSAIDs

costovertebral and costoransverse pain

• MOI ; blunt trauma, forceful coughing, poor posture, overuse 

• Complaints ; sharp localized pain with deep inhalation, trunk movement, or overhead arm movement, may report clicking sensation 

• Effects on ROM and strength ; trunk motion may be limited due to pain and normal strength 

• Diagnosis ; physical exam, r/o other conditions 

• Treatment ; mobilization/manipulation

costochondritis 

• MOI ; acute trauma or repetitive stress 

• Complaints ; anterior chest wall pain, tenderness over affected joint 

• ADLs affected ; labored breathing, lifting 

• Effects on ROM, strength, neuro ; normal 

• Diagnosis ; r/o cardiac pathology 

• Treatment ; rest, NSAIDs 

thoracic muscle strain

• MOI ; acute 

• Complaints ; spasm/tightness, no neuropathy, feels better at rest 

• ADLs affected ; active movements 

• Neuro ; normal 

• ROM and Strength 

  • Decreased strength with active contraction 

  • Decreased AROM due to pain or weakness, decreased passive ROM due to pain 

• Diagnosis ; MMT, important to r/o other pathologies 

• Treatment ; decrease pain, soft tissue work, TE to restore function

thoracic trigger points

• MOI ; acute, overuse, poor posture or psychological stress 

• Complaints ; localized sharp pain with referral pattern 

• Effects on ROM and strength ; may be decreased due to pain 

• Diagnosis ; physical exam, injection 

• Treatment ; massage, myofascial release, trigger point release, cupping, IASTM, dry needling, injection, TE

what is hyperkyphosis?

greater than 40 degrees kyphosis

what is scheuermanns disease?

juvenile form of hyperkyphosis

hyperkyphosis

• Diagnosis ; measurement of Cobb angle, standing lateral spine XR, kyphometer 

• Treatment ; TE (breathing correction, thoracic mobility, stability and strengthening, postural re-education)

scoliosis

• Complaints ; pain, muscle fatigue and or spasm 

• Effects on ROM and strength ; may have limitation to trunk motion 

  • Muscles on concave side usually shortened and tight 

  • Muscles on convex side usually lengthened and weak 

• Neuro ; typical normal 

• Diagnosis ; physical exam, XR 

• Treatment ; TE, orthosis, surgery

what side is the rib hump on in scoliosis?

convex

forward head posture

• Complaints ; pain in involved musculature 

• ROM and strength ; decreased strength in involved musculature 

• Diagnosis ; occiput to wall distance (OWD) 

  • Normal is 2-4 cm 

• Treatment ; TE, postural re-education

what causes forward head posture?

• Poor seated posture, constant use of electronics 

• Over training of anterior muscles and lengthened/weakened trapezius and rhomboids

upper crossed syndrome

• Tightness of suboccipitals, levator scapulae, and upper trapezius crossed with tightness of pectoralis major and minor 

• Weakness of cervical flexors crossed with weakness of rhomboids and middle/lower trap

what is associated with upper crossed syndrome?

forward head posture

how do you measure kyphosis?

kyphometer, occiput to wall distance

what is a significant occiput to wall distance?

> 2-4 cm

how is AROM of thoracic flexion/extension assessed?

seated with hands behind head

how is AROM of thoracic rotation/lateral flexion assessed?

hands across chest

T1 dermatome

anteromedial forearm and arm to axilla

T2 dermatome

medial arm to the axilla

T4 dermatome

nipple line

T6 dermatome

xiphoid process

T10 dermatome

umbilicus

T1-T4 myotome

serratus posterior superior

T9-T12 myotome

serratus posterior inferior

T1-T12 myotome

intercostals and upper erector spinae

T5-T12 myotome

rectus abdominus

T7-T12

external oblique

T7-L1 myotome

transverse abdominus and internal oblique

abdominal reflex

Stroke from lateral to medial in each of the four quadrants following dermatomal pathways and using the handle end of a reflex hammer

Adams forward bending test

• Pt stands with feet together, put hands together, bend straight forward 

• (+) rib hump and/or visible curvature 

• Indicates scoliosis

thoracic compression test

• Pt seated 

• Apply axial load by pressing down on shoulders 

• (+) if reproduces pain 

• Indicates discogenic pain or decreased foraminal space

thoracic foraminal closure test

• Pt seated 

• Passively flex to one side 

• Apply axial load by pressing down on shoulders 

• (+) if reproduces pain 

• Indicates decreased intervertebral foraminal space

anterior/posterior rib compression test

• Place hands on anterior and posterior rib cage and squeeze together 

• (+) pain or crepitus 

• Indicates a rib fx

lateral rib compression test

• Place hands on the sides of the rib cage and squeeze together 

• (+) pain or crepitus 

• Indicates rib fx

most common Dx

non-specific mechanical neck pain

cervical muscle strain

• MOI; typically acute, whiplash 

• Complaints ; localized pain, point tenderness, spasm, stiffness 

• ADLs affected l active movements 

• Neuro exam ; normal 

• ROM and strength ; 

  • Decreased strength and pain with active contraction 

  • Decreased AROM due to pain or weakness, decreased passive ROM due to pain 

• Diagnosis ; MMT, important to r/o pathologies 

• Treatment ; decrease pain, TE to restore function

torticollis (wryneck)

• Complaints ; stiffness, pain with attempt to align head to midline 

• Treatment ; pain management, manual therapy

what muscle is usually spasmed in torticollis?

SCM

what is the head positioning of torticollis?

ipsilateral flexion and contralateral rotation

cervical trigger points

• MOI ; acute, overuse, poor posture, or psychological stress 

• Complaints ; localized sharp pain with referral pattern 

• Effects on ROM and strength ; may be decreased due to pain 

• Diagnosis ; physical exam, injection 

• Treatment ; massage, myofascial release, trigger point release, cupping, IASTM, dryneedling, injection, TE

cervicogenic headaches

• Can be caused by any structure innervated by C1-C3 spinal nerves 

• MOI; trauma, whiplash , chronic muscle spasm 

• Diagnosis ; MRI or CT to dx underlying conditions or r/o other conditions 

• Treatment ; TE, manipulation, injection

cervical zygapophyseal (facet) joint sprain

• MOI ; acute or overuse 

• Complaints ; pain located just off the midline; can refer to occiput, posterior shoulder, parascapular region 

• ADLs affected ; extension moments 

• Neuro ; normal 

• Effects on ROM ; pain with extension, rotation, lateral flexion and axial load 

• Often hypertonic musculature and paraspinal tenderness 

• Diagnosis ; diagnostic injection therapy,  imaging is unreliable 

• Treatment ; NSAIDs, TE, spinal manipulation, traction, injection, radiofrequency ablation or medial branch

cervical facet joint syndrome/osteoarthritis

• MOI ; overuse 

• Complaints ; dull aching neck pain, paravertebral or posterolateral pain, worse in morning and improves with repetitive motion 

• Neuro ; normal 

• Effects on ROM ; pain with extension, rotation, axial load 

• Diagnosis ; imaging shows joint space narrowing, osteophyte formation, hypertrophy of the articular process, cysts, or subarticular bone erosion 

• Treatment ; medication, TE, injection, radiofrequency ablation of medial branch, surgery

what does the alar ligament connect?

foramen magnum of occiput to dens of C2

what does the alar ligament do?

limits lateral flexion and rotation

what does the transverse ligament do?

prevents anterior translation of C1 on C2

upper cervical instability

• MOI ; trauma, whiplash mechanism, long term postural disorder, rheumatoid arthritis 

• Complaints ; stiffness, diffuse pain, headaches, frequent need for manipulation 

• Neuro ; may see myotomes and dermatomes affected, or may present as normal

what joints are affected with upper cervical instability?

atlanto-occipital or atlanto-axial

what is the posterior ligament complex?

ligamentum flavum, interspinous ligament, supraspinous ligament

whiplash associated disorders

• Rapid acceleration-deceleration mechanism of energy transfer to the neck 

• Can involve facet joint/capsule, ligaments, vertebral arteries, musculature, discs

• MOI; MVA, trauma 

• Sx onset usually within 2 hours

quebec task force classification grade 0

no complaints about the neck, No physical signs

quebec task force classification grade 1

neck complaint of pain stiffness or tenderness only, no physical signs

quebec task force classification grade 2

neck complaint and MSK signs, decreased ROM and point tenderness

quebec task force classification grade 3

neck complaint and neuro signs, decreased ROM and point tenderness

quebec task force classification grade 4

neck complaint and fx or dislocation

jefferson fx

burst fx of C1

hangmans fracture

through pedicle or pars of C2

spinous process fx

hyperflexion (avulsion) hyperextension (contact or push-off fx)

cervical fx

• MOI ; trauma, axial compressive load, rapid flexion (seat belt injury), whiplash 

• Complaints ; pain and loss of function 

• ROM ; should not be performed if suspected 

• Neuro ; motor, sensory, reflexes can all suffer deficits 

• Diagnosis ; Xray, ct 

• Treatment ; cervical collar, traction, surgical stabilization 

cervical stenosis

• MOI ; overuse, degenerative 

• Complaints; neck and/or arm pain; radiculopathy into arm/hand, heaviness or weakness of UE, paresthesia or numbness in shoulder, arm, or hand, unilateral or bilateral 

• ADLs affected ; ROM and strength, fine motor control of hands/fingers 

• Neuro ; dermatomes, myotome, reflexes can all be affected 

• Diagnosis ; imaging to measure foraminal space, Xray, CT, MRI 

• Treatment ; bracing, TE, pain medication, injection, surgery (decompression or fusion)

cervical disc herniation

• MOI;  acute (compression, flexion, or extension) or overuse 

• Complaints; sharp pain with extension, radiating pain into arm/hand or parascapular region 

• May exhibit flat neck posture or splinting away from side of injury 

• ROM; decreased flexion, extension, lateral flexion, or rotation due to pain 

• Neuro; can have peripheral weakness, paresthesia, diminished reflexes 

• Diagnosis ; MRI, CT

• Treatment; TE, traction, steroid injection, surgery

where are cervical disc herniations most likely at?

C4-C7

cervical spondylosis

• MOI; insidious onset, overuse (aging) history of trauma 

• Complaints ; neck, occiput, or posterior shoulder pain, stiffness after prolonged inactivity

• Most cases are asymptomatic

• Effects on sensation, strength, neurologic exam all could be affected 

• Diagnosis ; MRI, xray, CT

• Treatment ; ice,heat, NSAIDs, TE, injection, surgery 

• Usually responds well to conservative treatment and activity modification

thoracic outlet syndrome

• MOI; overuse, secondary to previous trauma, postural deviation (rounded/depressed shoulders)

• Complaints ; pain (neck,shoulder, chest, arm),numbness, tingling, weakness or heaviness of hand/arm 

• Diagnosis ; physical exam, Xray, MRI, nerve conduction 

• Treatment ; manual therapy, TE, first rib mobilization/manipulation, NSAIDs, oral steroids, surgery

three locations of TOS

interscalene triangle, costoclavicular space, behind pec minor

brachial plexus injury

• MOI; traction or compression 

  • Rotation, lateral flexion, and compression or extension causes compression/impingement 

  • Direct impact to base of neck 

  • Forced contralateral flexion with ipsilateral depression of the shoulder causes traction 

• Signs and symptoms ; sharp burning pain radiating into arm, temporary weakness or decreased function, usually subsides within minutes 

• Usually does not involve cervical spine; if presenting with central pain clear c-spine 

• Neuro ; neuro deficits may persist for days or months

cervical myelopathy

• MOI; acute trauma, spondylosis, disc herniation, infection, tumor 

• Complaints; neck pain, numbness and paresthesia in distal extremities, atrophy of intrinsic hand muscles, bladder dysfunction 

• ADLs affected; difficulty with fine motor movements, gait 

• Neuro; myotomes and dermatomes can be affected, decreased or absent reflexes 

• Diagnosis; physical exam for clonus, babinski, hoffman, MRI, CT

candian c spine rules

• Patient age 65+, high energy incident/dangerous mechanism, or paresthesia in extremities 

  • High risk criteria- yes to any one of these ; send for imaging 

• Simple rear-end MVA, sitting position, ambulatory at anytime, absence of midline tenderness, delayed onset of pain 

  • Low risk criteria- presence of any of these five allows for removal of cervical collar to assess AROM 

• Unable to rate head 45 degrees 

alar ligament test

• Pt seated and place their head into flexion 

• Stabilize the C2 spinous process by grabbing it firmly, laterally 

• Rotate the head with opposite hand, feel for C2 spinous process movement 

• Side flex the head with the opposite hand, feel for C2 spinous process movement 

• (+)  not feeling movement at C2

• indicates alar ligament is not intact

modified sharp-purser test

• Stand to side of pt 

• Pt in slight flexion (if pain with this step, stop the test)

• Block with key pinch grip over C2 and apply PA force while stabilizing forehead with other hand 

• (+) translation or reduction of Sx

• indicates transverse ligament is not intact

cervical artery dysfunction

decreased blood flow to brain

end range rotation test

• Pt seated and will count backwards from 100 

• Hold at each end range position for 10 seconds and look for nystagmus or associated Sx 

• Rotate fully to one side, then return to neutral then rotate to the other side, then back to center

• (+) Sx of ataxia 

• indicates CAD

vertebral artery test

• Pt supine or seated 

• Passively move neck into extension and lateral flexion 

• Then rotate to same side and hold for 30 seconds 

• (+) nystagmus or pt reports dizziness (or other related Sx)

• indicates CAD

neuropathic origin clinical prediction rule

• Age > 45 y/o 

• (+) Hoffman's sign 

• (+) inverted supinator sign 

• (+) Babinski test 

• Gait abnormality

hoffmans sign

• Grasp middle finger, stabilizing proximal to DIP joint, and flick end 

• (+) flexion of all other fingers and thumb 

inverted supinator sign

• Brachioradialis reflex test (C6 N response is elbow flexion)

• (+) C7 response of elbow extension and finger flexion

babinski test

Great toe extension is (+), N response in flexion

C1 dermatome

top of head

C2 dermatome

temporal, occipital regions

C3 dermatome

posterior cheek, neck

C1 myotome

contributes to cervical flexion

C2 myotome

cervical flexion

C3 myotome 

cervical lateral flexion

axial compression test

• Pt seated with head in neutral 

• Apply downward pressure to top of head 

• (+) increase in pain 

• Indicates cervical radiculopathy 

• If negative perform with pt in lateral flexion 

• If negative in lateral flexion, then perform spurlings

spurlings test

• Pt seated with neck extended and rotated to side of complaint 

• Apply downward compressive force 

• (+) increase in pain 

• Indicates cervical radiculopathy

nerve root compression test (shoulder abduction test)

• Pt seated with hand (ipsilateral to reported Sx) placed on top of head 

• Hold for 10 sec 

• Relieves traction force of the limb 

• (+) reduction or relief of Sx 

• Indicates nerve root compression 

• If Sx increase think TOS