CHAPTER 42 • THORACIC AND LUMBAR SPINE 251- Gymnasts, in particular, demonstrate disc degenera-
tive changes and other abnormalities of the thora-
columbar spine seen on MRI. - There appears to be a significant correlation between
back pain and the decreased signal intensity and
abnormalities on MRI seen in gymnasts (Basmajian
and DeLuca, 1985).
BONESCAN
•A bone scan is useful to evaluate spondylolysis, neo-
plasm, infection, inflammatory arthritis, and pseu-
doarthrosis.ELECTRODIAGNOSTICS- Electrodiagnostics provide an objective picture of a
pathologic process and provide physiologic informa-
tion. - It may be used at the onset of nerve injury for evalua-
tion of the H reflex and motor unit recruitment. - It may also be used to determine recovery/chronicity.
LABORATORY
•A comprehensive evaluation may also include a com-
plete blood count (CBC) with differential, erythrocyte
sedimentation rate, and urinalysis, as well as other
specific tests as indicated.- Utilizing laboratory diagnostics is often appropriate to
determine if an infection or malignancy may be the
possible source of the back pain.
BIOMECHANICS- Thoracic spine mobility is limited by the rib cage.
- Rotation and sidebending are the primary motions of
the thoracic spine. - There is progressively increasing flexion and exten-
sion from T1 to T12, and progressively decreasing
rotation from T1 to T12. - Flexion occurs as the inferior articular process of
the superior vertebrae glides anterior and superior,
and is limited by the posterior longitudinal liga-
ment, interspinous ligament and the ligamentum
flavum. - Extension, which is the most restricted motion of the
thoracic spine, occurs as the inferior articular process
of the superior vertebrae glides posteriorly and inferi-
orly stretching the anterior longitudinal ligament and
the costal cage. - The lumbar spine region is capable of axial compres-
sion, forward flexion, extension, lateral flexion, and
rotation. - When the lumbar spine is in extreme flexion, there is
spontaneous electrical silence of the musculature.
•With initial flexion there is increasing activity of the
erector spinae muscles. - Progressing to mid flexion activates the gluteus max-
imus until late flexion which activates the ham-
strings.
•With lateral flexion of the lumbar spine, there is elec-
trical silence of the obliques, contralateral greater than
ipsilateral.
TABLE 42-1 Historical Information to Obtain When
Evaluating a Patient with Back Pain Complaints
Age and sport or occupation Onset- acute vs. insidious
of patient
Course (progressive, improving, Mechanism of injury
fluctuating, episodic)
Character of pain (sharp, dull, achy, History of injury
numbing, etc.)
Frequency of pain (constant Location/radiation of pain
vs. intermittent)
Paresthesias or abnormal sensory Weakness
complaints
Aggravating vs alleviating factors
(sitting, standing, walking,
supine, medication)
Pain with inspiration, expiration or both
and any difficulty breathing
Pain with coughing, sneezing or
straining (valsalva maneuver)
Any skin lesions that might be present Digestive complaints
History of surgery Medical history
Social history (tobacco, alcohol,
drug abuse)
Relation to work, automobile, or Nighttime pain and sleep
other related injury history
Time of day pain occurs or is worst
Any treatment that has been previously tried including medication,
therapy, modalities, manipulation, injection
RED FLAGSbowel or bladder dysfunction, history of cancer,
fever, unexplained weight loss, significant trauma, age >50, failure to
improve with appropriate treatment, alcohol, or drug abuse
Generalized disorders such as HIV/AIDS, drug use, Paget’s disease,
osteoporosis, or end stage renal disease warrants additional laboratory
or imaging studies.
Physical Examination
General appearance
Gait evaluation including heel and toe walking, tandem walking, one
foot stand, and squat and return to upright positioning
Inspection including posture
Palpation
Range of motion
Strength
Sensation to light touch/pinprick in the dermatomal and peripheral
nerve distribution
Muscle stretch reflexes/deep tendon reflexes and cutaneous reflexes
Upper motor neuron signs such as Babinski response, ankle clonus and
spasticity
Provocative maneuvers of the thoracic spine such as a sitting slump test,
passive scapular approximation, and first thoracic nerve root stretch
Provocative maneuvers of the lumbar spine such as the modified Schober
test, sitting slump test, straight leg raise, crossed straight leg raise,
bowstring test, reverse straight leg raise, Patrick’s/Faber’s, Gaenslen’s
test, measurement for leg length discrepancy