Spinal Orthopedic Exam

Diag-239 / Diag-739

Course Introduction

Jeremy Steel DC, ACP

 Patient Case
 Susan walks into your office with
tears in her eyes. She reports pain
and tingling in her arm and pain in
her shoulder. She has been a
ballroom dancer for the past 15
years. She is devastated because she
can’t dance with her husband.
 What does she have?
 Patient Case
 John was referred to your office by
his friend who has been seeing you
for quite some time. He runs a
construction company and is
concerned for his livelihood because
he can’t run his company properly.
He has moderate to severe low back
pain and pain in his left leg.
 What does he have?
 Orthopedic History
 In 1741, French physician and writer Nicholas Andry
wrote a book called Orthopaedia: or the Art of
Correcting and Preventing Deformities in Children.
Andry invented the word orthopaedics by combining
the Greek words orthos (straight) and paidion
(child), because the specialty was originally meant to
focus on correcting musculoskeletal issues like polio
and scoliosis in children.
 Purpose of Orthopedic
Testing
 Identify patient's condition
 Understand severity of patient
condition
 Know who to refer to
 Know what not to do with a patient
 Know what to do with a patient
 Basic Class Conditions
 Cervical joint disorder
 Cervical radiculopathy First
 Thoracic Outlet Syndrome Half of
 Lumbar joint disorder class
 Lumbar (Lumbosacral) radiculopathy
 SI joint disorder
 T4 syndrome
 Meningitis, Myelopathy Final is
Cumulati
 Malingering (Non-Organic)
ve
 Others…
By Cervical_Xray_Extension.jpg:
StillwaterisingCervical_Xray_Extension_view.jpg:
Stillwaterisingderivative work: F. Lamiot (talk) -
Cervical_Xray_Extension.jpgCervical_Xray_Extension_view.jpg, CC BY-SA
3.0, [Link]
By Mikael Häggström - Own work, CC0,
[Link]
By Nicholas Zaorsky, M.D. - Nicholas Zaorsky, M.D., CC BY-SA 3.0,
[Link]
 Section 1

Introduction to
Patient assessment
 LCCW Health Center

course-related exam forms

 Range of Motion (ROM)
LCCW Health Center form
 Components of patient assessment
brief notes

History:
 Chief Complaint (CC) / Present Illness (PI):
OPPQRST

 pain severity: use visual analog scale (VAS)

 function: use functional assessment

questionnaires

 outcomes: ongoing use of functional assessment

questionnaires
 Functional Assessment questionnaires  Outcome Assessment
measures
(“OATS” – Outcome Assessment Tools & Screens )

 Functional assessment questionnaires are validated

instruments designed to assess the impact of a patient’s
condition on their functional ability, quality of life/activities
of daily living (ADL).

 Using the instrument at later dates allows outcome

assessment.

 Neck: *Neck Pain Disability Index

*Neck Pain Disability Visual Analog Scale

 Low Back: *revised Oswestry

*Roland Morris Disability Questionnaire
(better for milder LBP)
 Review of Systems (ROS)
portion of case history:

The ROS consists of a series of questions about S&S

related to the various body systems (CV, Respir, GI,
GU, NS, etc).

The purpose of the ROS is to identify the potential

existence of health issues, other than the patient's
chief complaint, that may need further assessment
by the DC, or referral to a medical practitioner.
 ROS: Vital signs

 Height
 Weight
 Temperature
 Heart rate
 Respiration rate
 Blood pressure
 Inspection
(including, but not limited to):

 Signs of distress
 Cautious, restricted movements
 Antalgia, asymmetry, deformity
 Soft tissue findings (swelling, bruising, atrophy,
color)
 Atrophy
 fasciculations
 Palpation
(including, but not limited to):

 Tenderness
 Swelling
 Temperature
 Masses
 Hypertonicity
 Joint position, mobility
 Percussion:

 Assess for fractures of superficial bony processes

(spinous processes, etc.)

 Thorax/Abdomen: assess for changes in

percussion note
(change in density)
 Instrumentation
(including, but not limited to):
 tuning forks
 128 Hz for vibration sensation assessment, and

fracture assessment
 512 Hz for hearing assessment

 pinwheel (disposable): for pain sensation

assessment
 reflex hammer: for assessment of DTRs/MSRs
 2-point discriminator


 stethoscope: auscultation of heart, lungs,

abdomen, blood vessels (bruits)
 opthalmoscope/otoscope: visualization of fundus
of eye, ear, nose
 Range of Motion (ROM)

 How do the joints you are assessing move?

Symetry, Quality.
 Discussion of assessment of spinal ROM
will follow
 Orthopedic examination

 Detailed discussion of spinal orthopedic

exam will follow
 Neurologic exam

 mental status & language

 cranial nerve exam

 sensory: *pain/temp,
*tactile (light touch, vibration),
*cortical gnosis tests
 motor: *muscle strength,
*assessment of atrophy,
*fasciculations
 reflex: *DTRs/MSR,
*pathologic reflexes,
*superficial reflexes,
*visceral reflexes
 X-ray
 When do we take them? Why? How?
 minimum of 2 opposing views

 cervical spine:
 minimum of 3 views: AP, lateral, APOM

 radicular symptomatology: add obliques

 cervical trauma -7 views Davis series:

 add flexion & extension lateral views to help

identify ligamentous instability
 Laboratory studies

 based upon history & exam findings, used to

rule-in/rule-out suspected conditions, and
monitor co-morbidities:

 urinanalysis,
 CBC,

 blood chemistries
 Special studies

 ordered when there is clinical justification

 advanced imaging (MRI, CT, ultrasound, PET)

 electro-diagnostic tests (NCV, needle EMG,

EEG)

 CSF study (lumbar puncture/spinal tap)

ORTHOPEDIC EXAMS
 Orthopedic exams -
general principles
1. Orthopedic exams are biomechanical stress
exams. They involve compressing joints,
distracting joints, stretching soft tissues, etc.
Normally, these gentle biomechanical stresses
do not cause pain. However, when tissues are
compromised, pain may occur.

2. The location and quality of the pain

experienced by the patient is useful in
identifying the injured structure or tissue. For
example, local neck pain on cervical
compression is consistent with subluxation or
DJD, while pain, tingling and numbness down
the arm is indicative of radiculopathy.
 Orthopedic exams -
general principles

3. Rather than referring to a test as being

“positive” or “negative”, it is better to describe
the biomechanical stresses introduced and what
the patient experienced.
 Problems with orthopedic exams

1. Most tests are named after the originator

(eponym) rather than having biomechanically
descriptive names.

2. Occasionally, the same test may be known by

more than one name.

3. Tests are sometimes described slightly differently

in different textbooks.
 Problems with orthopedic exams

4. Texts usually describe a “classical” interpretation

which may be uncommon, while ignoring more
frequently occurring and common sense
interpretations.

5. Limited validity established in the literature for

most of these tests. Many of the test are less
specific than texts indicate.

6. These tests may aggravate the patient.

 Values of orthopedic tests

1. Sometimes these tests actually have diagnostic,

clinical value!

2. Knowledge of these exams is required for Clinic

exams, and National Boards

3. Performance may be expected by 3rd party

payers, legal depositions, etc.
 RATING THE DIAGNOSTIC VALUE OF
DIFFERENT ORTHOPEDIC TESTS

The Best Practice Utility Scale (BPUS)

Photographic Manual of Orthopedic and Neurologic Tests
5th ed., 2010
Joseph j. Cipriano

“In this edition, I have changed the sensitivity/reliability scale

to a Best Practice Utility Scale (BPUS) in order to evidence new
research. I have added a BPUS to each of the tests described
in this text. For each diagnosis presented there are multiple
tests. Some of those tests are more diagnostically valuable
than others. I have attempted to rate each test based on
currently available research. The scale is numbered from 0 to
4, with 1 to 2 being poorly diagnostically valuable, 2 to 3 being
moderately diagnostically valuable, and 3 to 4 being very
diagnostically valuable. Those tests that are very
diagnostically valuable should be performed first. This will
help in evaluating the patient’s condition more expeditiously.”
 “Sign” vs “Maneuver” vs “Test”

Sign: something the patient exhibits spontaneously

and you observe (a body posture or action that
relieves their symptom, or is an
involuntary reaction)

Maneuver: the doctor asks the patient to perform

some action

Test: the doctor performs an action on the patient

 “Sign” vs “Maneuver” vs “Test” - continued

These terms are not always used

consistently with their specific definition.

It is more important to recognize that the

mechanics are the same regardless of
whether the procedure is named a test,
maneuver, or sign.
 describing the abnormal finding(s)

Rather than referring to a test as being

“positive” or “negative”, it is better to
recognize the biomechanical stresses
introduced and what the patient
experienced.

Describe the location, type, and severity of

symptoms that were created or exacerbated
by the procedure – see the Health Center
exam forms.
 Describe what the
patient experienced
during the test –
be specific in regard
to:
 location

 type

 Severity

Example:
+ SLR – Pt
experienced
recreation of slight
tingling in L great
 Describing the finding(s) – “positive” &
“negative”
A “negative” finding is when the test does not
create or exacerbate (or relieve, if the test is
designed to relieve symptoms) the symptoms you
are assessing. Negative test findings help you
rule-out conditions.

A “true” positive finding is when the symptoms

elicited are as described in the initial test
descriptions.

A “false” positive finding is when symptoms are

elicited in the area being tested, but are not what
the test is designed for. These are still important
abnormal findings to note.
For example, when cervical compression causes
or exacerbates P/T/N in your patient’s upper
extremity it could be called a “true” positive
finding.

However, when cervical compression causes or

exacerbates local neck & diffuse shoulder pain it
could be called a “false” positive finding.
 “Incidental” finding

An “incidental” finding is an unexpected

finding outside the area being tested.

For example, low back pain when cervical

compression is performed.
Remember, it is important to consider the
location of symptoms (local vs radiating)
as well as the quality (pain, tingling,
numbness, deep achy, stabbing, etc.) to
determine what diagnosis best fits the
patient’s condition.
 A. Joint involvement (facet, degen.)
w/o radiculopathy

*cervical compression test

*variations of the cervical compression test

*lateral flexion (Jackson’s test)
*flexion/extension
*rotation
*modified Spurling test

*cervical distraction test

 B. Cervical Radiculopathy
(joint disorder w/ radiculopathy)

1. IVF stenosis 2. IVD syndrome

*cervical compression test *above tests for cerv. radicul

& variations due to IVF stenosis, plus:
*neutral
*lateral flexion (Jackson’s) *foraminal compression test
*extension in flexion
*rotation
*modified Spurling test *shoulder abduction relief sign
(Bakody’s sign)
*cervical distraction test
*Intrathecal Pressure tests
*Valsalva maneuver
*Naffzigger test
(jugular compression test)
 C. Adhesions

*shoulder depression test

*other tests that may cause stretching of the nerve

roots
 D. Soft tissue trauma

 O’Donahue’s test (strain vs sprain)

 other tests that cause stretching of soft

tissues but are not S/S tests.

 cervical distraction test

 shoulder depression test

 E. Fracture / dislocation

 Rust sign

 Soto-Hall test
 F. Meningeal irritation (Meningitis)

 Brudzinski sign

 Kernig test
 G. Thoracic Outlet Syndrome (TOS)
 Cervical rib syndrome: Adson’s test
modified Adson’s test

 Scalenus Anticus syndrome: Adson’s test

modified Adson’s test

 Costoclavicular syndrome: costoclavicular test

Eden’s test

 Pectoralis minor syndrome: Wright’s test

(hyperabuction syndrome) (hyperabduction
test)
 misc. TOS test

 various intermittent claudication tests:

 Elevated Arm Stress Test (EAST)

 intermittent claudication test

 Roos test
 test for vascular patency

 Allen’s test
 23. The Function of Innate
Intelligence – The function of Innate
Intelligence is to adapt universal forces
and matter for use in the body, so that all
parts of the body will have co-ordinated
action for mutual benefit.
 24. The Limits of Adaptation – Innate
Intelligence adapts forces and matter for
the body as long as it can do so without
breaking a universal law, or Innate
Intelligence is limited by the limitations of
matter.