The Patient History and Physical Examination: Cervical, Thoracic,

and Lumbar
By:
Armin Abas Soamole C111 09 353
Dian Ekawati C111 10 328
Tryastuti Wahyu Utami C111 11 348
Advisor :
dr. Padlan Pasallo
dr. Andika A. Thehumury
dr. Stefan A.G.P Kambey

Supervisor :
dr. Jainal Arifin , Sp.OT , (K) Spine
 This chapter addresses relevant issues in the history
and physical examination in patients with spine
disorders, particularly as these issues relate to the
assessment of patients seen commonly in clinical
practice, and provides information on how to identify
patients at risk for ongoing pain despite what seems
to be appropriate care for their structural problems.
 In the spine, the list of
discrete anatomic structures
with sensory innervation
includes muscles, tendons,
ligaments, fascia, anulus of
History and Physical A structure must be
the intervertebral discs,
Examination innervated to cause pain
bone, zygapophyseal
joints, dura mater, nerve
roots and dorsal root
ganglia, and vascular
elements
There is substantial overlap between the
referral patterns for anatomic structures of the
same spinal level, such as intervertebral discs
and zygapophyseal joints, and dermatomal,
myotomal, and sclerotomal referral patterns
at many spinal levels
 “Red Flags”—What Not to Miss

Historical Features of the Presenting

Complaint

Axial Versus Radicular Pain

Patient Demographics

Past Medical History

Family History

“Yellow Flags”—Predictors of Poor Outcome

in the Patient’s History
It is essential to identify all conditions that pose a substantial, imminent risk for further harm
to the patient. So we should identified specific “red flags” in the history of patients with low
back complaints that indicate the presence of such a condition;
Specifying the exact nature of the patient’s chief complaint and
provocative and palliative factors
The nature, onset, duration, and course of the primary complaint

History of previous injury; character and distribution of symptoms

Prior diagnostic testing and treatment

Other circumstances surrounding an injury (e.g., perceived fault, the

presence of workers’ compensation or litigation status); and
The degree of pain and disability perceived by the patient.
For all levels of the spine, pathology involving the musculotendinous
and ligamentous structures, zygapophyseal joints, vertebrae, and
anulus of the intervertebral discs tends to cause axial pain.

Structures in the cervical and thoracic regions that can result

in axial pain include

• soft tissue structures in the neck;

• vascular structures (e.g., aorta or carotid arteries);
• portions of the brachial plexus such as the long thoracic or suprascapular nerves;
• the proximal portion of ribs;
• costovertebral or costotransverse articulations;
• various structures within the shoulder; and various visceral structures, including
the pancreas, gallbladder, lung and pleura, and stomach or duodenum
If related to spine pathology, radicular pain implies neural compression from many
potential causes, including disc herniation, spinal canal or neuroforaminal stenosis, or
intrinsic disease of the spinal cord or nerve roots (e.g., herpes zoster).

Radicular pain in the thoracic region can result in a bandlike distribution on one or
both sides of the chest wall or abdominal region.

Additional structures that can result in radiating upper extremity pain include
•peripheral nerves such as the median nerve (e.g., carpal tunnel syndrome); ulnar nerve; portions of the brachial
plexus (e.g.,lower trunk plexopathies related to true neurogenic thoracic outlet syndrome or a Pancoast tumor);
vascular structures; the shoulder; the heart; and musculotendinous, ligamentous, or bony structures in the upper
extremities.
The family history is a necessary component of a complete medical history.

Although back pain and many other spinal conditions are common in the
general population, data suggest possible genetic risk factors for lumbar
degenerative disc disease.

Example: A family history of rheumatologic diseases, particularly

conditions associated with HLA B-27 such as ankylosing spondylitis, Reiter
syndrome, and inflammatory bowel disease, can suggest a tendency for, or
risk of, developing a similar process.
 Pain is an experience that is influenced by everything that is
currently occurring in the life of the patient.
 In a study of more than 25,000 subjects in 14 countries, the
World Health Organization found that physical disability is
more closely associated with psychological factors than with
medical diagnosis.
Regardless of the presence of anatomic pathology, it is
important to understand that a family member, a stressful
circumstance, regular use of opioid analgesics, money issues
related to compensation or litigation, and other factors can be
contributors to a patient’s on going pain and disability

Thorough evaluation of patients with back pain needs to include

some form of psychological testing because psychological
factors play a critical role in patient recovery from illness or
injury.
 visual analog scales functional scales psychological scales

• Million Visual Analog • Oswestry Low Back • The Fear-Avoidance

Scale Pain Disability Beliefs Questionnaire
• The McGill Pain Questionnaire, scale
Questionnaire • the modified Roland • Pain Catastrophizing
• Medical Outcomes scale, Scale
Study 36-item Short • Neck Disability Index,
Form Health Survey • Sickness Impact Profile
(SF-36) • Related Disability
Questionnaire, and the
SF-36.
• Oswestry
questionnaire,
• modified Roland scale
 Observation

Palpation

Neurologic Examination

Special Tests and Provocative Maneuvers

Non organic Signs

Additional Orthopaedic Assessment

 Range of motion, Movement patterns,
preferred postures, inconsistencies, and gait
abnormalities
 Formal observation should include an
examination from the feet to the head
Palpation may aid in the localization of the patient’s symptoms, the identification of an
injured structure, or the identification of associated soft tissue or bony abnormalities.

Localized tenderness should be distinguished from diffuse tenderness, the latter being
less consistent with a focal injury.

In the cervical spine

• palpation should include the occipital region; the anterior neck; the clavicular,
supraclavicular, and scapular regions; and the areas of the associated
cervicothoracic musculature.

In the thoracic region

• Palpation should also extend across the posterior ribs to identify focal bony
tenderness that may suggest rib pathology rather than spine pathology. Pain
with palpation or percussion of the costovertebral angle may suggest renal
pathology.79

In the lumbar region

• Palpation should include not only the lumbar spine but also the iliac crests,
sacrum, sacroiliac joints, ischial tuberosities, proximal hamstring and greater
trochanteric areas. Trochanteric pain may mimic pain from a spine etiology.
MOVEMENT
C5—elbow flexors, shoulder abductors and
external rotators
C6—elbow flexors, wrist extensors and pronators,  4—active movement against gravity and
shoulder external rotators
C7—elbow extensors, wrist pronators
C8—extension of index finger, finger abduction
and flexion, abduction of thumb
T1—finger abduction
L2—hip flexion
L3—hip flexion, hip adduction, knee extension
L4—knee extension, ankle dorsiflexion
L5—ankle dorsiflexion, great toe extension, ankle
eversion, hip abduction and internal rotation
S1—ankle plantar flexion, toe flexion
STRENGTH is generally graded on a scale of 1 to
5 as follows:
 5—active movement against full resistance
(normal strength)
some resistance
 3—active movement against gravity
 2—active movement with gravity
eliminated
 1—trace movement or barely detectable
contraction
 0—no muscular contraction identified
REFLEX
 Biceps reflex—C5, C6
 Brachioradialis reflex—C5, C6
 Triceps reflex—C6, C7
 Patellar tendon reflex—L2, L3, L4
 Medial hamstring reflex—L5, S1
 Ankle jerk reflex (Achilles tendon)—S1
 Lhermitte sign Spurling maneuver Valsalva maneuver

Femoral nerve
Lasègue sign or stretch test or
Dural tension signs
Bragard sign reverse straight-leg
raise,

Sacroiliac joint
test: Gillet, Patrick,
and Gaenslen tests.
 although more technically a symptom, is the presence of an electric shock–type
sensation radiating into the limbs with cervical flexion.

Although first described in a patient with multiple sclerosis, this sign is associated
with various spinal cord lesions. If elicited with neck flexion,this sign should raise
concern for the presence of a cervical cord lesion. If elicited with trunk flexion, this
may indicate a thoracic cord lesion.

video\L_Hermitte
Sign.mp4
 Spurling maneuver is a diagnostic test that
reproduces the compression mechanism of injury.

The patient’s neck is extended, laterally flexed to

the involved side, and rotated to the involved side
with axial loading applied while in that position.

video\Sp
urling_s
 Performed by having a patient hold his or her breath and
bear down.

A reproduction of the patient’s radicular symptoms or

spinal pain with this maneuver is believed to indicate a
space-occupying lesion, such as a disc herniation, in the
spinal canal.

video\Valsalva
Dural tension signs are frequently used to assess lumbar spine
pathology.

Many different maneuvers have been described. A supine

straight-leg raise is performed by elevating the leg with knee
extended and assessing for the reproduction of pain into the leg.

The test is considered positive if pain occurs between 30 degrees

and 70 degrees of elevation because no true change in tension on
the nerve roots is believed to occur outside of this range
 Tests proposed for assessing the sacroiliac
joint

video\Stork-
Flamingo-Gillet_s Test
.mp4
video\Gaenslen
Test.mp4
 Dilakukan dengan cara menaikkan
kaki smapai timbul gejala nyeri.
Kemudan kaki diturunkan dan
dilakukan dorsofleksi pasif. Positif
bila nyeiri menjalar.

video\Strai
ght Leg
 Crossed straight-leg raise, dilakukan dengan melakukan straight leg raise
pada kaki yang kontra lateral dari kaki yang bergejala. Bila timbul nyeri
pada kaki yang bergejala, maka positif.

The femoral nerve stretch test or reverse straight-leg raise, dilakukan

pada pasien dengan posisi telungkup atau prone kemudian lutut
difleksikan, positif bila ada nyeri yang menjalar sampai ke paha anterior.

Straight-leg raise test yang positif menandakan adanya tekanan pada akar
saraf lumbal bawah dan sakral. (L4,l5 dan S1). Femoral nerve test yang
positif menandakan adanya tekanan pada akar saraf lumbal atas (L2-L4)

video\Femoral Nerve
Stret.mp4
Waddel menjabarkan ada 5 tanda yang dapat ditemukan
pada pemeriksaan fisik, atau yang dikenal dengan
Waddel signs,yakni:
• Tenderness yang tersebar merata dan tidak sesuai lokasi anatomis.
• Gangguan motorik maupun sensorik yang tidak sesuai dengan lokasi
anatomik
• Verbalisasi nyeri yang berlebihan
• Adanya nyeri yang timbul dari dilakukannya tes dengan gerakan yang
spesifik.
• Adanya ketidakselarasan hasil saat tes yang sama dilakukanpada posisii
yang berbeda misalnya straight leg raise yang dilakukan pada posisi
duduk dan telentang.

Adanya 3 dari 5 gejala diatas menandakan adanya

gangguan non organik pada gejala nyeri pasien.
Anamnesis dan pemeriksaan fisik dari pasien dengan gangguan tulang
belakang adalah perkara yang kompleks. Sifat dari gejala yang diutarakan
pasien dan aspek-aspek yang relevan dari anamnesis sangat menentukan
pemriksaan diagnostik selanjutnya dan dengan demikian menentukan hasil
diagnosis.

Hanya dengan bicara dan melakukan pemeriksaan fisik langsung pada

pasien barulah penilai dapat mengerti sesungguhnya penyakit yang diderita
oleh pasien..