REIDER PART 2
71

Chapter 8_Ccrvical and Thoracic Spine 331

Spurling’s Test

If thc examiner is suspicious of lateralizing pathology, such as a disk prolapse, the compression maneuvcr may bc repeated with various amounts of cervical flexion, exten-sion, lateral bending, or rotation in an attempt to find the position that elicits the maximal response (Fig. 8-48). In Spurling’s test, the neck is extended and rotated toward the invoIved side prior to axial compression. This maneuver is designcd to exacerbate encroachment on a cervical nerve root by dccrcasing the dimensions of the foramen through which the nerve root exits thc spine. In response to the axial compression test or Spurlings test, a patient may feel no discomfort, a scnsation of heaviness, nonradicular or pseudoradicular pain, or radicular pain. Pain related to muscular strains or miki ligamentous sprains is not nor-mally aggravated by these tests. Nonradicular or pseudoradicular pain includes pain that radiates to the occiput, the scapula, or the shoulders, or occasionally down the arm but not distal to the elbow. Such pseudoradicular pain may be the result of a mechanical or degenerative process in the cervical spine such as spondylolisthesis or degenerativc disk disease without nerve root compression. Radicular pain radiates into the upper extrcmity, usually below thc elbow, along the distribution of a specific dcrmatomc. In thc younger individual, this is most commonly the result of nerve root compression owing to intervertebral disk prolapse. In the older patient, radicular pain is usually pro-duced by foraminal stenosis owing to the combination of disk degeneration and secondary facet hypertrophy.

Lhermitte’s Maneuver

Lhermitte^>s maneuver is performed by asking the seated patient to maximally flex the cervical and the thoracic spine (Fig. 8-49). Lhermitte^łs sign is considered present when this maneuver produces distal paresthesias in mul-tiple extremities or the trunk. Lhcrmittes sign is thought to bc indicative of spinał stenosis and resulting spinał cord compression. In the patient with a narrowed cervi-

Figure 8-48. Spurlings test.

Figurę 8-49. Lhermittes maneuver.

cal spinał canal, flexion can further reduce the dimensions of the canal, causing cord compression and the paresthesias described. In the patient without cervical spinał stenosis, maximal flexion simply results in a pulling sensation at the cervicothoracic junction without any radiating symptoms at all.

Nonorganic Signs of Waddell

Waddell described five signs that the examiner may notę during the initial evaluation that suggest the possibility of nonorganic pathology. These are physical findings that cannot be explained by current knowledge of anatomy and physiology. They are thought to represent functional or behavioral maladaptations to thc disease process or reaction to real or pcrccived pain. It should be borne firmly in mind that they are not pathognomonic of functional or nonorganic pathology, but rather they are just a component of the overall assessment. These signs were originally described in conjunction with the lumbar spine.

Nonanatomic Tenderness

The First of Waddell s signs is supcrficial nonanatomic tenderness. This sign is considered present when the patient reports disproportionate pain in response to extremely light touch or tenderness whosc distribution does not corrcspond to the configuration of known anatomie struc-tures (Fig. 8-50). The examiner must make this somewhat subjective judgment based on previous experience with the response of other patients to similar levels of pressure. If thc cxaminer senses that the patients pain response is out of proportion to the pressure applied during a normal examination, the examiner may wish to further test by pal-pating the involved area with extremely light pressure or by palpating structures that are seldom tender. It should be kept in mind that reflex sympathetic dystrophy and its variants may cause hypersensitivity in an cxtremity.

Simuiation Sign

Waddells second sign is called the simuiation sign. It is considered present if there is an exaggerated response to