Download Cervical Orthopedic Tests

Dr. Michael P. Gillespie
 Vascular Insufficiency may be aggravated by positional
change in the cervical spine.
 Assessment of the vertebrobasilar circulation must be
done if cervical adjustment or manipulation is to be
performed.
 Headaches, migraine
 Dizziness
 Sudden severe head or neck pain
 Hypertensive
 Cigarette smoking
 Oral Contraceptives
 Obesity
 Diabetes
 Positional change in the cervical spine compresses the
vertebral artery at the atlantoaxial junction on the side
opposite of rotation.
 In the normal patient, the diminished blood flow does
not cause any neurological symptoms, such as
dizziness, nausea, tinnitus, faintness, or nystagmus.
 Vertigo, dizziness, giddiness, light-headedness
 Drop attacks, loss of consciousness
 Diplopia
 Dysarthria
 Dysphagia
 Ataxia of gait
 Nausea, vomiting
 Numbness on one side of the face
 Nystagmus
 Procedure: Patient rotates head from one side to the
other.
 Positive Test: Vertigo, dizziness, visual blurring,
nausea, faintness, nystagmus.
 Structure affected: Vertebral artery on the same side
of head rotation. Consider patency of the carotid
arteries and the communicating cerebral artery circle.
 Procedure: Palpate and auscultate the carotid arteries
for pulsations and bruits. Instruct the patient to rotate
and hyperextend the head.
 Positive Test: If pulsation or bruits are present at
either the carotid or subclavian arteries the test is
positive.
 Structures Affected: It may indicate stenosis or
compression of the carotid or subclavian arteries.
 Procedure: Patient supine, head off table. Instruct pt.
to hyperextend and rotate head. Hold 15 to 30
seconds. Repeat opposite.
 Positive Test: Vertigo, dizziness, visual blurring,
nausea, faintness, and nystagmus.
 Structures Affected: Vertebral, basilar, or carotid
artery stenosis or compression.
 Cervical and upper back pain
 Cervical and upper back stiffness
 Cervical and upper trapezius tightness
 Reduced cervical range of motion
 Cervical extensor spasm
 Cervical strain is an irritation and spasm of the
muscles of the cervical spine with or without partial
muscle fiber tearing.
 Cervical sprain is a wrenching of the joints of the
cervical spine with partial tearing of its ligaments.
 Mild: Slight disruption of muscle fibers with no
appreciable hemorrhage and minimal amounts of
swelling and edema.
 Moderate: Laceration of muscle fibers with an
appreciable amount of hemorrhage into the
surrounding tissues and a moderate amount of
swelling and edema.
 Severe: Complete disruption of the muscle tendon
unit, possibly with tearing of the tendon from the
bone or a rupture of the muscle through its belly.
 Mild: Slight tears of a few ligamentous fibers.
 Moderate: More sever tearing of ligamentous fibers
but not complete separation of the ligament.
 Severe: Complete tearing of a ligament from its
attachments.
 Avulsion: A ligament that attaches to a bone is pulled
loose with a fragment of that bone.
 Procedure: Patient seated. Put the cervical spine
through resisted range of motion, then through
passive range of motion.
 Positive Test: Pain during resisted range of motion or
isometric muscle contraction signifies muscle strain.
Pain during passive range of motion may indicate a
sprain of any of the cervical ligaments.
 Structures Affected: Cervical spinal muscles and/or
cervical spinal ligaments.
 Since resisted range of motion mainly stresses muscles
and passive range of motion mainly stresses ligaments,
you should be able to determine between strain and
sprain or a combination thereof.
 Procedure: Patient seated. Head slightly flexed,
percuss the spinous process and associated
musculature of each cervical vertebrae with a reflex
hammer.
 Positive Test: Local pain may be a fractured vertebra
with no neurological compromise. Radicular pain may
be a fractured vertebra with neurological compromise
or a disc lesion with neurological compromise. A
ligamentous sprain could also elicit pain upon
percussion of the spinous processes.
 Procedure: A patient with severe injury to the upper
cervical spine will grasp the head with both hands to
support the weight of the head on the cervical spine.
The supine patient will support the head while
attempting to rise.
 Positive Sign: The patient stabilizes the head. It
might include slight traction.
 Structures Affected: This could represent severe
muscular strain, ligamentous instability, posterior disc
defect, upper cervical fracture, or dislocation.
 Severe cervical pain.
 Patient stabilizing the head.
 Little or no cervical motion.
 Severe cervical muscle spasm.
 Upper extremity neurological dysfunction.
 Lower extremity neurological dysfunction.
 Clinical Signs and Symptoms
 Cervical pain.
 Upper extremity neurological symptoms.
 Lower extremity neurological symptoms.
 Procedure: Have the patient bear down as if
defecating and focus the bulk of the stress on the
cervical spine. Ask if the patient feels pain and have
them point to the location.
 Positive Test: Local pain with increased pressure could
indicate a space-occupying lesion (e.g. disc defect,
mass, osteophyte) in the cervical canal or foramen.
 Procedure: Patient seated. Instruct them to cough,
sneeze, and bear down as if defecating (Valsalva’s
maneuver).
 Positive Test: Local pain or pain radiating to the
shoulders or upper extremities indicates an increase in
intrathecal pressure.
 Structures Affected: Space-occupying lesion.
 Clinical Signs and Symptoms
 Cervical pain.
 Upper extremity radicular pain.
 Loss of upper extremity sensation.
 Loss of upper extremity reflexes.
 Loss of upper extremity muscle strength.
 Procedure: Patient seated. Exert strong downward
pressure on the head. Repeat with b/l rotation.
 Positive Test: Local pain may indicate foraminal
encroachment without nerve root pressure or
apophyseal capsulitis. Radicular pain may indicate
pressure on a nerve root.
 Procedure: Laterally flex the head and exert strong
downward pressure. Perform b/l.
 Positive Test: Local pain may indicate foraminal
encroachment without nerve pressure or apophyseal
joint pathology. Radicular pain may indicate pressure
on a nerve root.
 Procedure: Laterally flex the patient’s head and
gradually apply strong downward pressure. If no pain
is elicited, put the patient’s head in a neutral position
and deliver a vertical blow to the uppermost portion of
the patient’s head.
 Positive Test: Local pain indicates facet joint
involvement. Radicular pain indicates nerve root
pressure.
 Procedure: Grasp beneath the mastoid processes and
press up on the patient’s head. This removes the
weight of the patient’s head on the neck.
 Positive Test: If local pain increases, suspect muscle
strain, spasm, ligamentous sprain, or facet capsulitis.
Relief of radicular pain indicates either foraminal
encroachment or a disc defect.
 Procedure: The patient should abduct the arm and
place the hand on top of the head.
 Positive Test: A decrease or relief of the patient’s
symptoms indicates a cervical extradural compression
problem (i.e. herniated disc, epidural vein
compression, or nerve root compression).
 Procedure: Patient standing. Stand directly behind
and inspect for scoliosis, hyperkyphosis, or
kyphoscoliosis. Next. Patient should flex forward at
hips. Inspect again.
 Positive Test:
 If scoliosis, hyperkyphosis, or kyphoscoliosis reduces
with forward bending: poor posture, overdevelopment
of unilateral spinal and/or upper extremity musculature,
nerve root compromise, leg length deficiency, or hip
contracture.
 If scoliosis, hyperkyphosis, or kyphoscoliosis does not
reduce with forward bending: structural deformity (i.e.
hemivertebra, compression fracture) or idiopathic
scoliosis.
 Procedure: Patient seated, head slightly flexed,
percuss the spinous processes and associated
musculature.
 Positive Test:
 Local pain may indicate a fractured vertebra without
neurological compromise or ligamentous sprain.
 Radicular pain may indicate a fractured vertebra with
neurological compromise or a disc defect with
neurological compromise.
 Procedure: Patient supine. Push down on sternum.
 Positive Test: Pressure on the sternum compresses the
lateral borders of the ribs. If a fracture is present here,
pain will be produced or exacerbated.
 Note: If trauma has occurred and you suspect a
fractured rib, radiographs should be performed first
before performing this test.
 Procedure: Patient supine. Patient should hook
fingers behind neck and raise the head towards the
feet. Mimic a sit-up.
 Positive Test:
 The umbilicus will not move in a patient with not
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thoracic root lesion.
Umbilicus moves superiorly: bilateral T10 – T12 lesion
Umbilicus moves superiorly and laterally: Unilateral T10
– T12 nerve root lesion on opposite side.
Umbilicus moves inferiorly: bilateral T7 – T10 nerve
root lesion.
Umbilicus moves inferiorly and laterally: Unilateral T7 –
T10 nerve root lesion of the opposite side.
 Procedure: Seated patient. Flex at waist to right and
left.
 Positive Test:
 Pain on side of lateral bending: intercostal neuritis.
 Pain on opposite side of lateral bending: fibrous
inflammation of the pleura or intercostal sprain.
 Procedure: Patient seated. Place a tape measure
around the patient’s chest at the level of the nipple.
Instruct patient to exhale and record the
measurement. Instruct the patient to inhale
maximally and record the measurement.
 Positive Test:
 Normal chest expansion for a man is 2 inches or more.
 Normal chest expansion for a woman is 1 inch or more.
 A decrease in chest expansion indicates an ankylosing
condition at the costotransverse or costovertebral
articulation.
Orthopedic Tests
 Procedure: Patient seated. Bent slightly forward. Tap
the spinous processes and associated musculature with
a reflex hammer.
 Positive Test: Local pain – fracture without
neurological compromise. Radicular pain – fracture or
disc defect with neurological compromise. Pain in
paraspinal musculature – muscle strain.
 Lower extremity pain may be referred from
lumbopelvic tissues or viscera. It may also be
radicular pain from the nerve roots of the spine.
 Referred pain patterns – the spinal pain is more
aggravating than the lower extremity pain. Referred
pain is poorly localized and dull.
 Radicular pain patterns – the leg pain is more
aggravating than the spinal pain. Radicular pain is
sharp and well localized.
 Neurogenic radicular lower extremity pain may be
caused by any one of several factors.
 Tension, irritation, or compression of a lumbar nerve
root or roots can cause radicular pain.
 Intraspinal canal compressions – disc lesions, spinal
stenosis, degenerative disc disease, hypertrophic
changes, malignancy.
 Extraspinal canal compressions – muscle dysfunction,
extradural defects, masses.
 Clinical Signs and Symptoms
 Lower back pain
 Lower extremity radicular pain
 Loss of lower extremity reflexes
 Loss of lower extremity muscle strength
 Loss of lower extremity sensation
 Procedure: Patient supine. Raise the patient’s leg to a
point of pain or 90 °, whichever comes first.
 Positive Test: This test stresses the sciatic nerve and
spinal nerve roots L5, S1, and S2.
 Pain after 70° of hip flexion – lumbar joint pain.
 Pain at 35° to 70° – sciatic nerve roots tense – pain
due to IVD pathology.
 Pain between 0° to 35° – extradural sciatic
involvement (spastic piriformis, SI joint lesion).
 Dull posterior thigh pain – tight hamstring.
 Procedure: Observe the patient while standing.
 Patients with disc protrusions that place pressure on a
nerve root will lean in a direction that reduces the
mechanical pressure on the disc.
 Positive Sign: If the disc protrusion is lateral to the
nerve root, the patient will lean away from the side of
pain.
 Leaning away pulls the nerve root medially away from
the disc defect and relieves pain.
 Positive Sign: If the disc protrusion is medial to the
nerve root, the patient will lean toward the side of
pain.
 Leaning towards the side of the lesion pulls the nerve
laterally away from the disc defect, reducing pressure
on the nerve root.
 Positive Sign: If the disc protrusion is central to the
nerve root, the patient may assume a flexed posture.
 Leaning forward puts the posterior portion of the disc
under traction, which can reduce the surface area of
the disc that comes into contact with the nerve.
 Procedure: Patient seated or standing. Stabilize the
PSIS with one hand. Reach around the patient with
the other hand and passively bend the dorsolumbar
spine obliquely backward.
 Positive Test: Pain in the lower back is a positive test
for lumbar spasm or facet capsulitis. Radicular pain
suggests a disc lesion.
 Space-occupying lesions can consist of the following:
 Disc defect, degenerative change, synovial cyst, fracture,
tumor, or some combination of these factors.
 Space-occupying lesions can lead to spinal stenosis.
 Narrowing of the tubular structures of the spine.
 Naorrowing of the central canal, lateral recess, or
intervertebral foramen.
 Clinical Signs and Symptoms
 Lower back pain
 Lower extremity radicular pain
 Lower extremity weakness
 Loss of lower extremity reflexes
 Loss of lower extremity sensation
 Procedure: Instruct the seated patient to bear down as
if straining at stool. Concentrate the stress at the
lumbar region. Ask if pain is increased and have the
patient point to it.
 Positive Test: The test increases intrathecal pressure.
 Positive test indicates a space-occupying lesion.
 Procedure: Patient seated. Instruct the patient to
cough, sneeze, and bear down as if straining at stool.
 Positive Test: Increased local pain suggests a spaceoccupying lesion.
 Lumbar and/or radicular pain in the leg can be caused
by either a lumbar condition or by a sacroiliac joint
condition.
 The following tests help to differentiate between the
two sources of pain.
 Clinical Signs and Symptoms:
 Lower back pain
 Sacroiliac joint pain
 Aggravated by sitting
 Alleviated by standing or walking
 Lower extremity radicular pain
 Procedure: Patient supine. Place one hand under the
lumbar spine with each finger under an interspinous
space. With the other hand perform a straight leg
raising test.
 Positive Test: Radicular pain before the fanning out of
the lumbar vertebra indicates an extradural lesion
such as a sacroiliac joint lesion. Radicular pain during
lumbar fanning indicates an intradural lesion such as a
space-occupying lesion. Local pain after lumbar
fanning indicates a posterior lumbar joint disorder.
 Procedure: Patient prone. Approximate the patient’s
heel to the buttock on the same side.
 Positive Test: Stretches the femoral nerve (largest
branch of the lumbar plexus). Radicular pain to the
anterior thigh – compression or irritation of the L2 –
L4 nerve roots by an intradural lesion. Pain in the
buttock – SI joint lesion. Pain in the lumbosacral joint
– lumbosacral lesion.