1. Thoracic and Lumbar
Spine Clinical Evaluation
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C

2. Clinical Evaluation
 History:
 Location of Pain:
 Pain radiating into extremities
 Peripheral paresthesia or numbness:
 Result of impingement or pressure on nerve root exiting
intervertebral foramen or dural irritation proximal to pain
site
 Pain Locations:
 Lumbar pain – possible ambiguous cause
 Sacroiliac pathology – pain around PSIS or radiating pain in
hip/groin
 Piriformis spasm – symptoms of sciatic nerve dysfunction

3. Clinical Evaluation

4. Clinical Evaluation
 History:
 Onset of Pain:
 Acute
 Chronic
 Insidious pain onset
 Note: Patient may
describe a single incident
that initiated pain,
although trauma is
probably an accumulation
or repetitive
stresses/microtrauma

5. Clinical Evaluation
 History:
 Mechanism of Injury:
 Movement: Flexion,
Extension, Lateral
Bending, Rotation
 Blunt Trauma: Direct
blow to
lumbar/thoracic area
 Contusions
 Compressive Stress:
 Hyperextension of
spine

7. Clinical Evaluation
 History:
 Pain Consistency:
 Constant Pain:
Unyielding (does not
improve with various
position of patient’s
spine)
 Example pathology –
Inflammation of dural
sheath

8. Clinical Evaluation
 History:
 Pain Consistency:
 Intermittent Pain:
 Mechanical Origin – certain spinal positions may ↑ or ↓
pain symptoms
 Compression/stretching of nerve root – Increase pain
 Positioning (flexion, traction) – lessen the pressure on
involved structure

9. Clinical Evaluation
 History:
 Bowel or bladder signs:
 Does the patient have any bowel or bladder
problems?
 Incontinence: Loss of bowel or bladder control
 May indicate lower nerve root lesions (cauda equina
syndrome), or spinal cord injury
 Description: urinary incontinence may range from
occasionally leaking urine (during cough/sneeze) to having
sudden episodes of strong urinary urgency

10. Clinical Evaluation
 History:
 Bowel or Bladder Signs:
 Cauda Equina Syndrome:
 Nerves within the spinal canal have been damaged
 Result: nerves supplying the muscles of the legs, bladder, bowel
and genitals do not function properly
 Patients experience numbness, loss of sensation and pain in the
legs, buttocks and pelvic region (damage usually permanent)
 Causes:
 Spina bifida (abnormality in closure of spinal canal)
 Tumors
 Injury (spinal fractures)
 Intravertebral disc herniation
 Vascular (blood vessel) problems or infections of the cauda
equina

11. Clinical Evaluation
 History:
 History of spinal injury:
 Previous injuries:
 Structural degeneration
 Predisposition to injury
 Changes in activity:
 Exercise habits (intensity
levels, duration,
frequency)
 Footwear, running
surfaces
 New bed

12. Clinical Evaluation
 General Inspection:
 Frontal Curvature:
 Alignment of lumbar,
thoracic, cervical vertebrae
with patient lying prone or
standing
 Normal alignment –
straight
 Abnormal alignment:
 Scoliosis – lateral
curvature (lumbar
and/or thoracic spine)

13. Clinical Evaluation
 General Inspection: Scoliosis
 Signs and symptoms:
 Uneven shoulders
 One shoulder blade appears more
prominent
 Uneven waist / 1 hip higher vs.
other
 Leaning to one side
 Back pain and difficulty breathing
(severe scoliosis)
 Causes:
 Idiopathic (85% of cases)
 Underlying neuromuscular disease,
leg-length discrepancy, birth defect,
fetal development (congenital)
 Not caused by poor posture, diet,
exercise, or the use of backpacks

14. Clinical Evaluation
 Diagnosis:
 Angle: X-ray
 Normal Spine (0
degrees)
 Scoliosis: (> 10
degrees)
 Complications:
(severe scoliosis)
 Lung and heart
damage:
compression of rib
cage against heart,
lungs
 > 70 degrees
 Back problems

15. Clinical Evaluation
 General Inspection:
 Scoliosis Test: Adam’s Forward Bend Test
 Patient Position: Standing with hands held in front (arms
straight)
 Evaluation Procedure: Patient bends forward, sliding hands
down the front of each leg
 Positive Test:
 Asymmetrical hump along lateral aspect of thoracolumbar spine
 One shoulder blade appears more prominent
 Uneven hips
 Implications:
 Functional scoliosis: scoliosis present when patient stands
straight, disappears during flexion
 Structural scoliosis: present during both standing and with flexion

16. Clinical Evaluation

17. Clinical Evaluation
 General Inspection:
 Sagital Curvature:
 Normal Alignment:
 Lordotic cervical
 Kyphotic thoracic
 Lordotic lumbar
 Kyphotic sacral

18. Clinical Evaluation

19. Clinical Evaluation
 General Inspection:
 Observation of GAIT:
 Spinal pain –
influence on walking
and running gait
 Slouching
 Shuffling
 Shortened gait

20. Clinical Evaluation
 General Inspection:
 Skin Markings:
 Café-au-lait spots:
presence of darkened
areas of skin
pigmentation
 Normal (benign)
 Collagen disease
 Neurofibromatosis 1
 95% of patients
will display spots

21. Clinical Evaluation
 General Inspection:
 Skin Markings: Sign of Neurofibromatosis-1
 Neurofibromatosis-1:
 Autosomal dominant disease
 Characterized by formation of neurofibromas (tumors
involving nerve tissue) in the skin, subcutaneous
tissue, cranial nerves, and spinal root nerves
 Implications: growth of tissue along the nerves – puts
pressure on affected nerves and cause pain and severe
nerve damage
 Loss of nerve function (sensation, movement)

22. Clinical Evaluation
 General Inspection:
 Breathing patterns:
 Irregular breathing (i.e. shallow respirations, pain)
 Injury to thoracic vertebrae
 Pressure on thoracic nerves
 Trauma to ribs, costal cartilage
 Bilateral comparison of skin folds:
 Asymmetry of natural folds
 Causes: muscle imbalance, ↑ or ↓ kyphosis, scoliosis

23. Clinical Evaluation
 General Inspection:
 Kyphosis:
 Abnormal forward rounding
of the upper back (> 40 to 45
degrees)
 Round back or hunchback
 Causes:
 Developmental problems,
degenerative diseases
(arthritis), osteoporosis with
compression fractures,
trauma
 Severe cases:
 Can affect lungs, nerves,
causing pain and other
problems

24. Clinical Evaluation
 General Inspection:
 Kyphosis Test: Forward
bend test
 Patient bends forward
from the waist while ATC
views the spine from the
side
 With kyphosis, the rounding
of the upper back may
become more obvious in this
position
 Postural kyphosis – the
deformity corrects itself when
patient lies on their back

25. Clinical Evaluation
 Postural kyphosis:
 May improve on its own
 Exercises to strengthen back muscles, correct posture, and
sleeping on a firm bed
 Structural kyphosis:
 Caused by spinal abnormalities
 Scheuermann's disease:
 Developmental disorder that causes a stooped forward or bent-
over posture
 Affects between 0.5% and 8% of the general population
 Osteoporosis-related kyphosis:
 Multiple compression fractures
 Low bone density

26. Clinical Evaluation

27. Clinical Evaluation
 General Inspection:
 Movement and Posture:
 Poor posture (standing,
sitting, bending)
 Lordotic Curve:
 Reduction:
 Muscle spasm
 Hamstring tightness
 Increased:
 Hip flexor tightness
 Abdominal weakness

28. Clinical Evaluation

29. Clinical Evaluation
 General Inspection:
 Standing Posture:
 Lateral shift in trunk and pelvis
 Nerve root impingement (lateral shift ↓ pressure)
 Erector Spinae Muscle Tone:
 Unilateral hypertrophy or atrophy
 Faun’s Beard:
 Spina bifida occulta

30. Clinical Evaluation
 General Inspection: Spina Bifida
 Birth defect that occurs when the tissue surrounding the developing
spinal cord doesn't close properly
 Spina Bifida Occulta:
 Mildest form, results in a small separation in one or more of the
vertebrae of the spine (spinal nerves usually not involved – most
patients have no signs/symptoms or neurological problems)
 Inspection: Faun’s Beard, a collection of fat, a small dimple or a
birthmark on the newborn's skin above the spinal defect
 Complications:
 Minor physical disabilities
 Mental strain
 Severity:
 Size and location of the neural tube defect
 Does skin cover the area?
 Do the spinal nerves come out of the affected area of the spinal cord?

31. Clinical Evaluation

32. Clinical Evaluation
 Palpation: Thoracic Spine
 Spinous Processes
 Supraspinous Ligaments:
 Fills space between the spinous processes
 Costovertebral Junction:
 Articulation between ribs and thoracic vertebrae
 Only palpable on slender individuals
 Trapezius:
 Origin to insertion
 Rhomboids and levator scapulae lie deep to middle/upper traps
 Paravertebral Muscles
 Scapular Muscles

33.  1 – Spinous Processes
 2 – Supraspinous
Ligaments
 3 – Costovertebral
Junction
 4 – Trapezius
 5 – Paravertebral
Muscles
 6 – Scapular Muscles

34. Structure Landmark
Cervical vertebral bodies Same level as spinous processes
C1 transverse process One finger’s breadth inferior to mastoid process
C3-C4 vertebrae Posterior to hyoid bone
C4-C5 vertebrae Posterior to thyroid cartilage
C6 vertebrae Posterior to cricoid cartilage; moves during flexion and
extension of cervical spine
C7 vertebrae Prominent posterior spinous process
T1 vertebrae Prominent protrusion inferior to cervical spine
T2 vertebrae Posterior from jugular notch of the sternum
T3 vertebrae Even with the medial border of the scapular spine
T7 vertebrae Even with the inferior angle of the scapula
L3 vertebrae Posterior from the umbilicus
L4 vertebrae Level with the iliac crest
L5 vertebrae Typically demarcated by bilateral dimples, but variable
from person to person
S2 At level of the posterior superior iliac spine

35. Clinical Evaluation
C7
T1
T2
T3
T4
T5

36.  1 – Spinous Processes
 2 – Step-off Deformity
 3 – Paravertebral Muscles

37. Clinical Evaluation
 Spondylolisthesis:
 Forward slippage of a vertebrae on the one below it
 L4 and L5 / L5 and S1
 Affects 5-6% of males, 2-3% of females
 Causes:
 Strenuous physical activity (weightlifting, gymnastics, football)
 Types:
 Developmental:
 May exist at birth, or may develop during childhood (generally not
noticed until later in childhood/adult life)
 Acquired:
 Degeneration: caused by the daily stresses that are put on spine
(i.e. carrying heavy items, physical sports)
 Connections between the vertebrae weaken
 Single or repeated force

38. Clinical Evaluation
 Spondylolisthesis:
 Grade 1:
 25% of vertebral body has
slipped forward
 Grade 2:
 50%
 Grade 3:
 75%
 Grade 4:
 100%
 Grade 5:
 Vertebral body completely
fallen off
(i.e.,spondyloptosis)

39. Clinical Evaluation
 Symptoms:
 May be asymptomatic
 Low back pain (especially
after exercise)
 ↑ lordosis
 Pain/weakness in one or
both legs
 ↓ ability to control bowel/
bladder functions
 Tight hamstrings
 Advanced spondylolisthesis:
changes may occur in the
way patient stands/walks

40. Clinical Evaluation
 Palpation: Sacrum and Pelvis
 Median sacral crests
 Iliac crests:
 Palpate laterally from PSIS to find iliac crests and anteriorly to locate
ASIS (level of symmetry)
 Posterior superior iliac spine
 Gluteals
 Ischial tuberosity
 Greater trochanter
 Sciatic nerve:
 Place thumb on ischial tuberosity and 3rd finger on the PSIS. 2nd finger
will fall into sciatic notch (nerve most superficial as it passes by ischial
tuberosity)
 Pubic symphysis

41. 1 – Median sacral crests
2 – Iliac crests
3 – PSIS
4 – Gluteal muscles
5 – Ischial tuberosity
6 – Greater trochanter
7 – Sciatic nerve
8 – Pubic symphysis

42. 1 – Iliac crest
2 – Tensor fascia latae
3 – Gluteus medius
4 – Iliotibial band
5 – Greater trochanter
6 – Trochanteric
bursa

43. 1 – Pubis
2 – ASIS
3 – AIIS
4 – Sartorius
5 – Rectus femoris

44. Clinical Evaluation
 Active Range of Motion:
 Flexion and Extension:
 Measured with patient standing
 Distance from the fingertips to the floor can be
measured (accuracy affected by tightness of
hamstrings and calf muscles and scapular
protraction)
 Gravity assists with movement
 More accurate than hook-lying position
 Abdominal muscles have to overcome weight of the
trunk

45. Clinical Evaluation
 Active Range of Motion:
 Lateral Bending:
 Patient standing (feet shoulder width apart and the hand
opposite the direction of the movement resting on the ilium)
 Patient bends trunk laterally (attempt to tough fingertips to the
ground)
 Distance between the ground and fingertips is measured
 Rotation:
 Patient is sitting position (stabilizes pelvis and lower extremity)
 Patient rotates shoulder girdles and spinal column (attempt to
look behind one’s back)
 Movement primarily occurs in thoracic spine

46. Clinical Evaluation
 Passive Range of Motion:
 Flexion:
 Patient in hook-lying position
 Examiner brings the knees to the chest by lifting under the
knees and thighs and flexing the hip and thoracic spine
 Extension:
 Patient prone (hands flat on table at shoulder level – push-up
position)
 Patient extends arms, lifting the torso (hips and legs remain of
table)
 Rotation:
 Patient in hook-lying position
 Patient’s pelvis and legs are rotated to bring lateral portion of
the knee towards the table (shoulders remain flat)

47. Spinal Ligaments Stressed During Passive Range of
Motion Testing
Motion Ligaments Stressed
Flexion Posterior Longitudinal Ligament,
Supraspinous Ligament, Interspinous
Ligament, Ligamentum Flavum
Extension Anterior Longitudinal Ligament
Rotation Interspinous Ligament, Ligamentum
Flavum
Lateral Bending Interspinous Ligament, Ligamentum
Flavum

48. Clinical Evaluation
 Beevor’s Sign:
 Test for thoracic nerve inhibition
 Patient performs an abdominal curl-up from hook-lying
position
 Normal Findings: abdominal muscles receive concurrent
innervation from T5-T12 nerve roots (umbilicus does not move)
 Positive Test: umbilicus is pulled toward the head
 Characteristic of spinal cord injury between T6 and T10 levels
 Upper abdominal muscles (rectus abdominis) are intact at
the top of the abdomen but weak at the lower portion, patient
is asked to do a sit up – only the upper muscles contract
(umbilicus pulled toward the head)

49. Clinical Evaluation
 Resistive Range of Motion:
 Flexion:
 Patient position – supine with knees flexed and feet
flat on table
 Stabilization – pelvis
 Resistance – applied to the superior sternum as
patient lifts the scapulae off the table
 Muscles tested – rectus abdominis, internal oblique,
external oblique

50. Clinical Evaluation
 Resisted Range of Motion:
 Extension:
 Patient position – prone with arms interlocked
behind the head
 Stabilization – lower lumbar region
 Resistance – applied to upper thoracic spine as
patient lifts head, chest, and arms off table
 Muscles tested – iliocostalis lumborum, iliocostalis
thoracis, longissimus thoracis, spinalis thoracis,
semispinalis thoracis, rotators, latissimus dorsi

51. Clinical Evaluation
 Resisted Range of Motion:
 Rotation:
 Patient position – supine (hands interlocked behind
head)
 Stabilization – opposite ASIS
 Resistance – anterior aspect of shoulder as it is
rotated off the table
 Muscles tested – internal oblique, external oblique
(opposite side), rotators, multifidi