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Anesth Pain Med 2011; 6: 101108

radiculopathic pain

Received: January 25, 2011.Accepted: March 20, 2011.Corresponding author: Kang Ahn, M.D., Chronic Pain Center, Medical College of CHA University, 605, Yeoksamdong, Kangnamku, Seoul 135-060, Korea. Tel: 82-2-3468-3099, Fax: 82-2-3468-3344, E-mail: fmriver@netsgo.com

Segmental palpation for radiculopathy

Kang Ahn

Chronic Pain Center, CHA University, Seoul, Korea

The success of intramuscular stimulation relies heavily on a thorough physical examination by a competent practitioner, trained to recognize the physical signs of segmental changes according to segmental innervations of the spinal nerve. These segmental changes are influenced by descending pathways from higher centers of the CNS and/or ascending pathways from peripherally innervated areas. These changes are actual phenomena but are frequently unrecognized by imaging studies such as X-rays, CT scans and MRI. To find abnormal segmental changes, a physical examination with exact palpation is essential. Therefore, in this chapter, we introduce the segmental changes in view of a physical examination and target areas according to dermatomes of the spinal nerve from the cervical and lumbosacral regions. (Anesth Pain Med 2011; 6: 101108)

Key Words: Palpation, Physical examination, Segmental changes.

(orthodromic activation) (antodromic activation) [1]. . .

, [2]. [3-5]. , [6]. [7-10]. segmental vertebral cellulotenoperiosteao-myalgic syndrome[11] (segmental faci-litation or facilitated segment) [12]. (antidromic activation), (orthodromic acti-vity) . .

(Table 1), , [12]. , , cellulalgia , , , , , (Table 2).

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Table 1. Sequence of Physical Examination for Musculoskeletal Pain

1) History taking including event, duration, worsening factor, relieving factor.

2) Check posture, gait3) Palpation on painful soft tissue and joint. 4) Palpation on spine, inter-spinous process, transverse process5) Range of motion of spine. 6) Neurologic examination7) Segmental diagnosis (peripheral change on palpation which

innervated by same spinal nerve+ spine changes on palpation of the same segment)

Table 2. Considerations for Palpation of Pathologic Changes

Palpation of spineThe examination is usually nonpainful in normal segment. If pain is provoked, this suggests abnormal pathology of the segment. 1) Axial pressure on interspinous ligament with thumb or index finger.2) Friction-pressure over the facet joint with thumb or index finger3) Transverse pressure on spinous process

Palpation of skin1) A fold of skin is pinched firmly between the thumb and index finger. 2) Rolled between the fingers in one direction and then in the other. Skin And subcutaneous tissue irritability is characterized by increased

texture thickness with tenderness. 3) This examination should be performed bilaterally and segmentally. 4) Often there is excess fluid in the subcutaneous tissues, as in Trophedema.5) Orange peel appearance when skin rolling.

Palpation of muscle, ligament, tendon1) Trigger points are most localized to the same part of the same muscles, tendons, and ligaments for the same spinal segment.2) The pathologic muscles present as one or several taut band that are very tender when pressed a point or rubbed transversely on

muscle bands with thumb or index finger. 3) Thickened or tendered tendons or ligaments are present especially on insertion or joint which they pass.

Fig. 1. (A) Palpation of the posterior tubercle with the patients neck side-flexed at 15 degrees to the opposite side. Notice the SCM muscle in frontof it. To facilitate the palpation, draw an imaginary line along the transverse processes and trace the locations of the posterior tubercles. Palpationof the splenius muscle which is as thick as a pencile at the back of the transverse tubercles and palpation of the lateral surface of zygopophyseal joints at the back of the splenius. (B) Palpation of the cervical zygopophyseal joints with an examiners index finger at the sides of the semispinalmuscles while the patient is lying on the back maintaining the natural C-curve of the neck.

, , (interspinous space)

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Fig. 2. Cellulalgia at C2 innervation. Thedark area is where the patient has pain. The hypersensitized skin is painful whenpinched and rolled. (A) lateral view, (B)posterior view.

Fig. 3. Cellulalgia at C3 innervation.

[11,13]. . . (Fig. 1). 4 , 1 , 2 , 3 , 4 . 12 . 3, 4 . C2-3 C3-4, C4-5, C5-6, C6-7, C7-T1 . Maigne C2-3 T1-2 . 1 , [13].

facilitated segment

Maigne[11] cellulalgia . pinch roll test . , C 2-3

. cellulalgia [11,12], cellulalgia . 2 : , , , 90 , 2, 3 . (Fig. 2). 3 : , 3 .

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Fig. 4. Cellulalgia at C4 and C5 innervation.

Fig. 5. The pain along the inner margin of the scapular and over the infraspinatus may be associated with the pathology of C6, 7, 8 nerve roots as well as C5. The over the infraspinatus, deltoid and acromion is often associated with the cellulalgia at C5 innervation.

Fig. 6. Cellulalgia and trigger point in the back and the arm innervated by C6 nerve root. The muscles related with C6 to be tested with a thrustback and forth are marked by black lines. The upper; biceps, the middle;the extensors of the wrist and fingers and the lower; the extensor of thethumb.

(hyperalgesia) (Fig. 3). C3-4, C2-3 C3 . C3-4 C2-3. . 4 : C4 . C4-5 C4 (Fig. 4). 5 : C5

, . (transverse friction) (Fig. 5). 6 : C6 , (Fig. 6).

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Fig. 7. Cellulalgia at C7 innervation. The black lines represent the area-upper 1/3 of the pronator teres and the transverse carpal ligament-in which the transverse friction test is performed. The referred pain alongthe medial side of scapular is the same as that of C6 nerve root.

Fig. 8. Cellulalgia at C8 innervation. The black lines indicate the areasfor the physical examination. At 3cm below from the origin of the flexor carpi ulnaris, the transverse friction test is undertaken (in the upper right).The pinch and roll test is performed at the thenar area (in the lower right).

7 : C7 1/3 . (transverse carpal liga-ment) (Fig. 7). 8 : C8 (medial epicondyle) . (flexor carpi ulnaris) 3 (Fig. 8).

. 45 [14,15]. , . (spondylo-listhesis) - (Flexion-extension view) .

.

-

- - , [16]. . - - . , - , , - L2 . , . , , . cellulagia (Fig. 9).

. L4-5 ,

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Fig. 9. Cellulalgia at T12 and L1 innervation. The dysfunction in the thoracolumbar junction is associated with the pain in the dermatome of the posterior primary ramus(1) and that of the anterior primary ramus(2,3)as well as the back pain. This is confirmed by the pinch and roll test with the affected skin and the existence of tenderness at the interspinous space in the thoracolumbar junction. Palpation at the interspinous spaceis performed from T10/11 to L2/3 with the patient bending forward or lyingon the chest on the bed with the feet on the ground. The transverse friction test on the skin 7-8cm apart from the midline over the iliac crest-up and down or side to side -can reproduce the pain that the patient presents with by irritating cluneal nerve.

Fig. 10. Cellulalgia at L2 and L3 inner-vation and the related back pain area. Cellulalgia is clearly detected by the pinch and roll test. The problem in the iliolumbar ligament can be confused with that of L5 nerve root. So the mus-cle test for adductors is necessary unless there is the sensory dysfunction associated with L2.

. , (flexion and extension view) . ,

(dural tube) . L2 L3 L2, L3 L4 , L3 L4 L3, L4 L5, L4 L5 L4, L5 S1 . L5 S1 L5, S1 S2 . L2, L3 : L1-2 L2-3 L2, L2-3 L3-4 L3 . (dorsal rami) [17]. (ventral rami) cellu-lalgia . , . L3, S1, L5 . L2 L3 . (quadratus lumborum), (iliopsoas), (hip adductors) . 90 (hip flexion)

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Fig. 11. The pain from the dorsal ramusof L4 or zygopophyseal joint between L3 and L4. The cellulalgia and the severe pain are identified by the pinch roll test on the skin below the knee innervated by the saphenous nerve.

Fig. 12. Cellulalgia and pain from the dosal ramus of L5. The pinch androll test on the skin over the anterior tibialis is easy to diagnose it.

Fig. 13. Cellulalgia and pain from the dosal ramus of S1. Palpation of muscles at the motor point, trigger points and tender points of lateral headof the gastrocnemius is important in the segmental diagnosis of S1 byway of transverse friction. The pinch and roll test is performed for detecting cellulalgia at the upper 1/3 of the gastrocnemius.

(hip abduction) 60 , cellulagia (Fig. 10). L4 : L4 . L4 . cellulalgia (saphenous nerve) (inferior branch) (Fig. 11).

L5 : L5 L4 L5 . S1 . L4/5 , L4 L5 (multifidus) . L3 L4

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. L3 L4 , (Fig. 12). (gluteus medius) L5 . L5 , , . . S1 : L4 L5 , , S1 . S1 L5 S2 , cellulalgia (Fig. 13). L4/5 , , . . L5 S1 L4 L5 . L4 L5 . , L4-5 . , , S1 S2 .

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