Thoracolumbar Spine - Clinical Tree

Clinical Summary and Recommendations

Patient History
Complaints	A few subjective complaints appear to be useful in identifying specific spinal pathologic conditions. A report of “no pain when seated” is the answer to the single question with the best diagnostic utility for lumbar spinal stenosis (+LR [likelihood ratio] = 6.6). “Pain not relieved by lying down,” “back pain at night,” and “morning stiffness for longer than 1/2 hour” are all somewhat helpful in identifying ankylosing spondylitis (+LR = 1.51 to 1.57). Subjective complaints of weakness, numbness, tingling, and/or burning do not appear to be especially helpful, at least in identifying lumbar radiculopathy.
Physical Examination
Neurologic Screening	Traditional neurologic screening (sensation, reflex, and manual muscle testing) is reasonably useful in identifying lumbar radiculopathy. When tested in isolation, weakness with manual muscle testing and, even more so, reduced reflexes are suggestive of lumbar radiculopathy, especially at the L3-L4 spinal levels. Sensation testing (vibration and pinprick) alone does not seem to be especially useful. However, when changes in reflexes, muscular strength, and sensation are found in conjunction with a positive straight-leg raise test, lumbar radiculopathy is highly likely (+LR = 6.0). In addition, a finding of decreased sensation (vibration and pinprick), muscle weakness, or reflex changes is modestly helpful in identifying lumbar spinal stenosis (+LR = 2.1 to 2.8).
Range-of-Motion, Strength, and Manual Assessment	Measuring both thoracolumbar range of motion and motor control, as well as trunk strength, has consistently been shown to be reliable, but the findings are of unknown diagnostic utility. The results of studies assessing the reliability of passive intervertebral motion (PIVM) are highly variable, but generally, the reports are of poor reliability when assessing for limited or excessive movement and of moderate reliability when assessing for pain. Diagnostic studies assessing PIVM suggest that abnormal segmental motion is moderately useful both in identifying radiographic hypomobility/hypermobility and in predicting the responses to certain conservative treatments. However, restricted PIVM may have little or no association with low back pain.
Special Tests	The centralization phenomenon (movement of symptoms from distal/lateral regions to more central regions) has been shown to be both highly reliable and decidedly useful in identifying painful lumbar discs (+LR = 6.9). The straight-leg raise test, crossed straight-leg raise test, and slump test have all been shown to be moderately useful in identifying nerve root impingement and disc pathologic conditions, including bulges, herniations, and extrusions. Palpation of gluteal trigger points appears to be helpful in both identifying and ruling out radicular low back pain (+LR = 8.6, –LR = .28). A 2011 systematic review identified the passive lumbar extension test as a useful clinical test in identifying lumbar segmental instability (+LR = 8.8). Both the Romberg test and a two-stage treadmill test have been found to be moderately useful in identifying lumbar spinal stenosis.
Interventions	Patients with low back pain of less than 16 days’ duration and no symptoms distal to the knees and/or patients who meet at least four out of the five criteria proposed by Flynn and colleagues should be treated with lumbosacral manipulation. Patients with low back pain who meet at least three out of the five criteria proposed by Hicks should be treated with lumbar stabilization exercises.

Anatomy

Osteology

Arthrology

Joints of the Thoracic Spine

Figure 4-3, T7, T8, and T9 vertebrae, posterior view.

Figure 4-4, Sternocostal articulations, anterior view.

Thoracolumbar Joints	Type and Classification	Closed Packed Position	Capsular Pattern
Zygapophyseal joints	Synovial: plane	Extension	Lumbar: significant limitation of side-bending bilaterally and limitations of flexion and extension Thoracic: limitation of extension, side-bending, and rotation; less limitation of flexion
Intervertebral joints	Amphiarthrodial	Not applicable	Not applicable

Thoracic Spine	Type and Classification	Closed Packed Position	Capsular Pattern
Costotransverse	Synovial	Not reported	Not reported
Costovertebral	Synovial	Not reported	Not reported
Costochondral	Synchondroses	Not reported	Not reported
Interchondral	Synovial	Not reported	Not reported
Sternocostal (first joint)	Amphiarthrodial	Not applicable	Not applicable
Sternocostal (second to seventh joints)	Synovial	Not reported	Not reported

Ligaments

Costovertebral Ligaments

Ligaments	Attachments	Function
Radiate sternocostal	Costal cartilage to the anterior and posterior aspects of the sternum	Reinforces joint capsule
Interchondral	Connect adjacent borders of articulations between costal cartilages 6 and 7, 7 and 8, and 8 and 9	Reinforces joint capsule
Radiate ligament of head of rib	Lateral vertebral body to head of rib	Prevents separation of rib head from vertebra
Costotransverse	Posterior aspect of rib to anterior aspect of transverse process of vertebra	Prevents separation of rib from transverse process
Intraarticular	Crest of the rib head to intervertebral disc	Divides joint into two cavities

Thoracolumbar Ligaments

Ligaments	Attachments	Function
Anterior longitudinal	Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs	Maintains stability and prevents excessive extension of spinal column
Posterior longitudinal	Extends from the sacrum to C2. Runs within the vertebral canal attaching the posterior vertebral bodies	Prevents excessive flexion of spinal column and posterior disc protrusion
Ligamenta flava	Binds the lamina above each vertebra to the lamina below	Prevents separation of the vertebral laminae
Supraspinous	Connect spinous processes of C7-S1	Limits separation of spinous processes
Interspinous	Connect spinous processes of C1-S1	Limits separation of spinous processes
Intertransverse	Connect adjacent transverse processes of vertebrae	Limits separation of transverse processes
Iliolumbar	Transverse processes of L5 to posterior aspect of iliac crest	Stabilizes L5 and prevents anterior shear

Muscles

Thoracolumbar Muscles: Superficial Layers

Muscles	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Latissimus dorsi	Spinous processes of T6-T12, thoracolumbar fascia, iliac crest, inferior four ribs	Intertubercular groove of humerus	Thoracodorsal nerve (C6, C7, C8)	Humerus extension, adduction, and internal rotation
Trapezius (middle)	Superior nuchal line, occipital protuberance, nuchal ligament, spinous processes of T1-T12	Lateral clavicle, acromion, and spine of scapula	Accessory nerve (CN XI)	Retracts scapula
Trapezius (lower)		Lateral clavicle, acromion, and spine of scapula	Accessory nerve (CN XI)	Depresses scapula
Rhomboid major	Spinous processes of T2-T5	Inferior medial border of scapula	Dorsal scapular nerve (C4, C5)	Retracts scapula, inferiorly rotates glenoid fossa, stabilizes scapula to thoracic wall
Rhomboid minor	Spinous processes of C7-T1 and nuchal ligament	Superior medial border of scapula	Dorsal scapular nerve (C4, C5)
Serratus posterior superior	Spinous processes of C7-T3, ligamentum nuchae	Superior surface of ribs 2-4	Intercostal nerves 2-5	Elevates ribs
Serratus posterior inferior	Spinous processes of T11-L2	Inferior surface of ribs 8-12	Ventral rami of thoracic spinal nerves 9-12	Depresses ribs

CN, Cranial nerve.

Thoracolumbar Muscles: Intermediate Layer

Figure 4-10, Muscles of the back, intermediate layer.

Muscles	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Iliocostalis thoracis	Iliac crest, posterior sacrum, spinous processes of sacrum and inferior lumbar vertebrae, supraspinous ligament	Cervical transverse processes and superior angles of lower ribs	Dorsal rami of spinal nerves	Bilaterally: extend spinal column Unilaterally: side-bend spinal column
Iliocostalis lumborum		Inferior surface of ribs 4-12
Longissimus thoracis		Thoracic transverse processes and superior surface of ribs
Longissimus lumborum		Transverse process of lumbar vertebrae
Spinalis thoracis		Upper thoracic spinous processes

Thoracolumbar Muscles: Deep Layer

Figure 4-11, Muscles of the back, deep layer.

Muscles	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Rotatores	Transverse processes of vertebrae	Spinous process of vertebra one to two segments above origin	Dorsal rami of spinal nerves	Vertebral stabilization, assists with rotation and extension
Interspinalis	Superior aspect of cervical and lumbar spinous processes	Inferior aspect of spinous process superior to vertebrae of origin	Dorsal rami of spinal nerves	Extension and rotation of vertebral column
Intertransversarius	Cervical and lumbar transverse processes	Transverse process of adjacent vertebrae	Dorsal and ventral rami of spinal nerves	Bilaterally stabilizes vertebral column. Ipsilaterally side-bends vertebral column
Multifidi	Sacrum, ilium, transverse processes of T1-T3, articular processes of C4-C7	Spinous process of vertebra two to four segments above origin	Dorsal rami of spinal nerves	Stabilizes vertebrae

Anterior Abdominal Wall

Figure 4-12, Dynamic “corset” concept of lumbar stability.

Muscles	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Rectus abdominis	Pubic symphysis and pubic crest	Costal cartilages 5-7 and xiphoid process	Ventral rami of T6-T12	Flexes trunk
Internal oblique	Thoracolumbar fascia, anterior iliac crest, and lateral inguinal ligament	Inferior border of ribs 10-12, linea alba, and pecten pubis	Ventral rami of T6-L1	Flexes and rotates trunk
External oblique	External aspects of ribs 5-12	Anterior iliac crest, linea alba, and pubic tubercle	Ventral rami of T6-T12 and subcostal nerve	Flexes and rotates trunk
Transversus abdominis	Internal aspects of costal cartilages 7-12, thoracolumbar fascia, iliac crest, and lateral inguinal ligament	Linea alba, pecten pubis, and pubic crest	Ventral rami of T6-L1	Supports abdominal viscera and increases intraabdominal pressure

Fascia

The thoracolumbar fascia is a dense layer of connective tissue running from the thoracic region to the sacrum. It is composed of three separate and distinct layers: anterior, middle, and posterior. The middle and posterior layers blend together to form a dense fascia referred to as the lateral raphe. The posterior layer consists of two distinctly separate laminae. The superficial lamina fibers are angled downward and the deep lamina fibers are angled upward. Bergmark has reported that the thoracolumbar fascia serves three purposes: (1) to transfer forces from muscles to the spine, (2) to transfer forces between spinal segments, and (3) to transfer forces from the thoracolumbar spine to the retinaculum of the erector spinae muscles. The transverse abdominis attaches to the middle layer of the thoracolumbar fascia and exerts a force through the lateral raphe, resulting in a cephalad tension through the deep layer and a caudal tension through the superficial layer of the posterior lamina. ^, ^, The result is a stabilizing force exerted through the lumbar spine, which has been reported to provide stability and assist with controlling intersegmental motion of the lumbar spine.

Nerves

Nerve Ventral Rami	Segmental Level	Sensory	Motor
Intercostals	T1-T11	Anterior and lateral aspect of the thorax and abdomen	Intercostals, serratus posterior, levator costarum, transversus thoracis
Subcostals	T12	Anterior and lateral aspect of the thorax and abdomen	Part of external oblique
Dorsal rami	T1- T12	Posterior thorax and back	Splenius, iliocostalis, longissimus, spinalis, interspinales, intertransversarii, multifidi, semispinalis, rotatores
Subcostal nerve	T12	Lateral hip	External oblique
Iliohypogastric nerve	T12, L1	Posterolateral gluteal region	Internal oblique, transverse abdominis
Ilioinguinal	L1	Superior medial thigh	Internal oblique, transverse abdominis
Genitofemoral	L1, L2	Superior anterior thigh	No motor
Lateral cutaneous	L2, L3	Lateral thigh	No motor
Branch to iliacus	L2, L3, L4	No sensory	Iliacus
Femoral nerve	L2, L3, L4	Thigh via cutaneous nerves	Iliacus, sartorius, quadriceps femoris, articularis genu, pectineus
Obturator nerve	L2, L3, L4	Medial thigh	Adductor longus, adductor brevis, adductor magnus (adductor part), gracilis, obturator externus
Sciatic	L4, L5, S1, S2, S3	Hip joint	Knee flexors and all muscles of the lower leg and foot

Figure 4-15, Nerves of the lumbar spine.

Figure 4-16, Nerves of the lumbar spine.

Patient History

Lumbar Zygapophyseal Joint Referral Patterns

Figure 4-17, Lumbar zygapophyseal joint pain referral patterns. Zygapophyseal pain patterns of the lumbar spine as described by Fukui and colleagues. Lumbar zygapophyseal joints L1-L2, L2-L3, and L4-L5 always referred pain to the lumbar spine region. Primary referral to the gluteal region was from L5-S1 (68% of the time). Levels L2-L3, L3-L4, L4-L5, and L5-S1 occasionally referred pain to the trochanteric region (10% to 16% of the time). Primary referral to the lateral thigh, posterior thigh, and groin regions was most often from L3-L4, L4-L5, and L5-S1 (5% to 30% of the time).

Area of Pain Referral	Percentage of Patients Presenting with Pain (n = 176 Patients with Low Back Pain) ∗
Left groin	15%
Right groin	3%
Left buttock	42%
Right buttock	15%
Left thigh	38%
Right thigh	38%
Left calf	27%
Right calf	15%
Left foot	31%
Right foot	8%

∗ Prevalence of pain referral patterns in patients with zygapophyseal joint pain syndromes as confirmed by diagnostic blocks. In a subsequent study, it was determined that in a cohort of 63 patients with chronic low back pain, the prevalence of zygapophyseal joint pain was 40%.

Thoracic Zygapophyseal Joint Referral Patterns

Figure 4-18, Zygapophyseal pain patterns of the thoracic spine.

Reliability of the Historical Examination

Historical Question and Study Quality		Population	Reliability
Increased pain with	Sitting	A random selection of 91 patients with low back pain	Interexaminer κ = .49
	Standing		Interexaminer κ = 1.0
	Walking		Interexaminer κ = .56
	Lying down		Interexaminer κ = .41
Pain with sitting		95 patients with low back pain	Interexaminer κ = .99 to 1.0
Pain with bending		95 patients with low back pain	Interexaminer κ = .98 to .99
Increased pain with coughing/sneezing15		A random selection of 91 patients with low back pain	Interexaminer κ = .64
Patient report of	Foot pain	Two separate groups of patients with low back pain (n ₁ = 50, n ₂ = 33)	Interexaminer κ = .12 to .73
	Leg pain		Interexaminer κ = .53 to .96
	Thigh pain		Interexaminer κ = .39 to .78
	Buttock pain		Interexaminer κ = .33 to .44
	Back pain		Interexaminer κ = −.19 to .16
Increased pain with	Sitting	53 subjects with a primary complaint of low back pain	Test-retest κ = .46
	Standing		Test-retest κ = .70
	Walking		Test-retest κ = .67
Pain with bending		53 subjects with a primary complaint of low back pain	Test-retest κ = .65
Pain with bending		Two separate groups of patients with low back pain (n ₁ = 50, n ₂ = 33)	Interexaminer κ = .51 to .56
Increased pain with coughing		53 subjects with a primary complaint of low back pain	Test-retest κ = .75
Pain with pushing/lifting/carrying		53 subjects with a primary complaint of low back pain	Test-retest κ = .77 to .89

Diagnostic Utility of Red Flags in Identifying Serious Pathology

Historical Question and Study Quality	Patient Population	Reference Standard	Sens	Spec	+LR	−LR
Age ≥ 75	669 patients >55 years of age seen in primary care for 1st episode of low back pain with or without leg pain	Radiologic diagnosis of vertebral fracture	.45 (.28, .62)	.85 (.82, .88)	3.1 (2.0, 4.7)	.60 (.50, .90)
Trauma			.21 (.07, .35)	.97 (.95, .98)	6.2 (2.8, 13.5)	.80 (.50, 1.3)
Osteoporosis			.38 (.21, .54)	.88 (.86, .91)	3.2 (1.9, 5.2)	.70, (.50, .90)
Back pain intensity score ≥7/10			.67 (.51, .83)	.63 (.59, .67)	1.8 (1.4, 2.3)	.50 (.30, .90)
Thoracic back pain			.42 (.26, .59)	.78 (.75, .81)	1.9 (1.3, 3.0)	.70 (.50, 1.0)
≥1/5 of above features			.88 (.77, .99)	.42 (.38, .46)	1.5 (1.3, 1.8)	.30 (.10, .70)
≥2/5 of above features			.70 (.54, .85)	.81 (.78, .84)	3.6 (2.8, 4.8)	.40 (.20, .60)
≥3/5 of above features			.30 (.15, .46)	.95 (.93, .97)	5.8 (3.2, 10.8)	.70 (.60, .90)
Any of the following 4 factors: 1. Anticoagulant use 2. Decreased sensation of physical exam 3. Pain that is worse at night 4. Pain that persists despite appropriate treatment	329 adult patients presenting to emergency department with nontraumatic low back pain	Serious outcome as the identification of any one of the following underlying pathologies within 30 days of the initial visit: compression fracture, osteomyelitis, spinal abscess, malignancy, cauda equina syndrome, severe disc prolapse requiring surgery, any condition requiring immediate intervention (i.e., abdominal aortic aneurysm, retroperitoneal tumor, bleeding or infection that required treatment, spinal stenosis requiring surgery, or death)	.91 (.71, .99)	.55 (.49, .61)	2.0 (1.7, 2.4)	.17 (.04, .62)

Diagnostic Utility of Patient History in Identifying Lumbar Spinal Stenosis

Historical Question and Study Quality	Patient Population	Reference Standard	Sens	Spec	+LR	−LR
Age over 65 years	93 patients with low back pain 40 years old or older	Lumbar spinal stenosis per attending physician’s impression; 88% also supported by computed tomography (CT) or magnetic resonance imaging (MRI)	.77 (.64, .90)	.69 (.53, .85)	2.5	.33
Pain below knees?			.56 (.41, .71)	.63 (.46, .80)	1.5	.70
Pain below buttocks?			.88 (.78, .98)	.34 (.18, .50)	1.3	.35
No pain when seated?			.46 (.30, .62)	.93 (.84, 1.0)	6.6	.58
Severe lower extremity pain?			.65 (.51, .79)	.67 (.51, .83)	2.0	.52
Symptoms improved while seated?			.52 (.37, .67)	.83 (.70, .96)	3.1	.58
Worse when walking?			.71 (.57, .85)	.30 (.14, .46)	1.0	.97
Numbness			.63 (.49, .74)	.59 (.42, .76)	1.5	.63
Poor balance			.70 (.56, .84)	.53 (.36, .70)	1.5	.57
Do you get pain in your legs with walking that is relieved by sitting?	45 patients with low back and leg pain and self-reported limitations in walking tolerance	Lumbar spinal stenosis per MRI or CT imaging	.81 (.66, .96)	.16 (.00, .32)	.82 (.63, 1.1)	1.27
Are you able to walk better when holding onto a shopping cart?			.63 (.42, .85)	.67 (.40, .93)	1.9 (.80, 4.5)	.55
Sitting reported as best posture with regard to symptoms			.89 (.76, 1.0)	.39 (.16, .61)	1.5 (.90, 2.4)	.28
Walking/standing reported as worst posture with regard to symptoms			.89 (.76, 1.0)	.33 (.12, .55)	1.3 (.80, 2.2)	.33

Diagnostic Utility of Patient History in Identifying Lumbar Radiculopathy

Historical Question and Study Quality	Patient Population	Reference Standard	Sens	Spec	+LR	−LR
Patient reports of:	170 patients with low back and leg symptoms	Lumbosacral radiculopathy per electrodiagnostics
Weakness			.70	.41	1.19	.73
Numbness			.68	.34	1.03	.94
Tingling			.67	.31	.97	1.06
Burning			.40	.60	1.0	1.0

Diagnostic Utility of Patient History in Identifying Ankylosing Spondylitis

Clinical Symptom and Study Quality	Patient Population	Reference Standard	Sens	Spec	+LR	−LR
Pain not relieved by lying down	449 randomly selected patients with low back pain	The New York criteria and radiographic confirmation of ankylosing spondylitis	.80	.49	1.57	.41
Back pain at night			.71	.53	1.51	.55
Morning stiffness for longer than ½ hour			.64	.59	1.56	.68
Pain or stiffness relieved by exercise			.74	.43	1.30	.60
Age of onset 40 years or less			1.0	.07	1.07	.00

Physical Examination Tests

Neurologic Examination

Diagnostic Utility of Sensation Testing, Manual Muscle Testing, and Reflex Testing for Lumbosacral Radiculopathy

Test and Study Quality		Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
Sensation (vibration and pinprick)		Considered abnormal when either vibration or pinprick was reduced on the side of the lesion	170 patients with low back and lower extremity symptoms	Electrodiagnostic testing. Radiculopathy defined as the presence of positive sharp waves; fibrillation potentials; complex repetitive discharges; high-amplitude, long-duration motor unit potentials; reduced recruitment; or increased polyphasic motor unit potentials (of more than 30%) in two or more muscles innervated by the same nerve root level but different peripheral nerves	.50	.62	1.32	.81
Weakness	Gastrocnemius and soleus	Weakness was defined as any grade of less than 5/5			S1 = .47	S1 = .76	1.96	.70
	Extensor hallucis longus				L5 = .61	L5 = .55	1.36	.71
	Hip flexors				L3-L4 = .70	L3-L4 = .84	4.38	.36
	Quadriceps				L3-L4 = .40	L3-L4 = .89	3.64	.67
Reflexes	Achilles	Considered abnormal when the reflex on the side of the lesion was reduced compared with the opposite side			S1 = .47	S1 = .9	4.70	.59
Reflexes	Patellar				L3-L4 = .50	L3-L4 = .93	7.14	.54
Reflexes	Achilles	Test is positive if reflex is absent	100 patients with lumbar disc herniation diagnosed by MRI	Lumbar disc herniation diagnosed by MRI with level of herniation intraoperatively confirmed	S1 = .83	S1 = .57	1.93	.30
	Medial hamstring				L5 = .76	L5 = .85	5.07	.28
	Patellar				L3-L4 = .88	L3-L4 = .86	6.29	.14
Reflexes + Weakness + Sensory		All three abnormal	170 patients with low back and lower extremity symptoms	Electrodiagnostic testing. Radiculopathy defined as the presence of positive sharp waves; fibrillation potentials; complex repetitive discharges; high-amplitude, long-duration motor unit potentials; reduced recruitment; or increased polyphasic motor unit potentials (of more than 30%) in two or more muscles innervated by the same nerve root level but different peripheral nerves	.12	.97	4.00	.91
Reflexes + Weakness + Sensory + Straight-leg raise test		All four abnormal			.06	.99	6.00	.95
Reflexes + Weakness + Sensory + Straight-leg raise test		Any of four abnormal			.87	.35	1.34	.37

Figure 4-20, Clinical features of herniated lumbar nucleus pulposus.

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