examination of spine
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Examination of SPINE
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Exposure
Clothed only in underpants
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Look
1. Gait Normal walking
wide base gait – cervical myelopathy waddling gait – proximal myopathy
Walking on tip toe – S1 weakness Walking on heels – L5 weakness
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2. Standing(a)Look from the side
i. normal spine> cervical lordosis> thoracic kyphosis> lumbar lordosis
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ii. Increased kyphosis (posterior convexity of the spine)
> senile kyphosis (with osteoporosis, osteomalacia or pathological
fracture)> Scheuermann’s disease
(osteochondritis involving one or more of the
vertebrae)> ankylosing spondylitis
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iii. Gibbus (angular kyphosis)> fracture> tuberculosis of the spine> congenital abnormality
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iv. Lumbar curvature> flattening or reversal of lumbar lordosis :
- prolapsed intervertebral disc- osteoarthritis of the spine- infection of vertebral bodies- ankylosing spondylitis
> increase in lumbar lordosis- may be normal (esp. in women)- spondylolisthesis- secondary to increased thoracic
curvature or to flexion deformity of the hips
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(b) Look from behindi. listing of trunk (due to muscle spasm)ii. Scoliosis (lateral curvature of spine)
- postural : scoliosis disappears with forward flexion of the spine- structural : scoliosis persists with
forward flexion of the spine and a rib hump presents
iii. Shoulder tiltiv. Pelvic tilt
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v. Skin changes over the spine- hair tuft (spina bifida)- sinus - colour changes or pigmentation (neurofibroma)- scar
vi. Swellingvii. Prominent crease of the trunkviii. Wasting of glutei, hamstrings and calf
muscles
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Feel
along the spinous process, looking for tenderness
paravertebral muscle spasm sacro-iliac joint tenderness step deformity (spondylolisthesis)
- Slide the fingers down the lumbar spine on to the sacrum
- A palpable step at the lumbo-sacral junction
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Move Thoracic and Lumbar spine• Flexion
- ask the patient to try to touch his toes- watch the spine for smoothness of movement and any areas of restriction- patients with advanced ankylosing spondylitis have a flat ankylosed spine and all the bending occur at the hips
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Lumbar spine excursion test (Schober’s method)
- Mark 2 points 10cm apart at the midline of lumbar spine
- Anchor the top of the tape with a finger and ask the patient to flex as far as he can
- Measure the increase in the distance between the 2 points which indicate lumbar excursion
- Normal excursion = 5 cm or more
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2. Extension- ask the patient to arch his back- assist him by steadying the pelvis and pulling back on the shoulder- normal : 30°
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3. Lateral flexion- ask the patient to slide the hands down the side of each leg in turn- record the point reached from the floor or- measure the angle- normal : 30-45°
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4. Rotation - patient seated to fix the pelvis or pelvis fixed by examiner- ask the patient to twist round to each side- normal : 45°
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Cervical spine1. Flexion
- ask the patient to bend the head forwards- chin should be able to touch the chest- normal : 80°
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2.Extension- ask the patient to look up and back- normal : 50°
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3. Lateral flexion- ask the patient to touch his shoulder with the ear- involve atlanto-axial and atlanto-occipital joints- normal : 45°
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4. Rotation - ask the patient to look over his shoulder- normal : 80°- restricted and painful in cervical spondylitis
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Neurological Examination
UPPER LIMB1. Tone hypertonia : UMNL normotonia hypotonia : LMNL
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2. Power i. Shoulder
- abduction : C5,C6- adduction : C6,C7,C8
ii. Elbow- flexion : C5,C6- extension : C7,C8
iii. Wrist- flexion : C6,C7- extension : C7,C8
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iv. Fingers- flexion : C7,C8- extension : C7,C8- abduction : C8,T1- adduction : C8,T1
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3. Reflex - biceps jerk : C5,C6- triceps jerk : C7,C8- brachioradialis (supinator) jerk : C5,C6
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4. SensationC5 – lateral armC6 – lateral forearm
- thumb & index fingerC7 – middle fingerC8 – ring&little fingerT1 – medial arm
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LOWER LIMB1. Tone hypertonia : UMNL normotonia hypotonia : LMNL
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2. Power i. Hip
- flexion : L2,L3- extension : L5,S1,S2- abduction : L4,L5,S1- adduction : L2,L3,L4
ii. Knee- flexion : L5,S1- extension : L3,L4
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iii. Ankle- plantar flexion : S1,S2- dorsiflexion : L4,L5
iv. Tarsal joint- eversion : L5,S1- inversion : L5,S1
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3. Reflex- knee jerk : L3,L4- ankle jerk : S1,S2- plantar reflex : L5,S1,S2
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4. SensationL1 – groinL2 – anterior thighL3 – anterior kneeL4 – medial legL5 – lateral leg
- medial of foot dorsumS1 – lateral of foot dorsum
- heel and foot soleS2 – posterior leg and thigh
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Special Tests
1. Straight leg raising test- do on normal limb 1st- raise the leg from the couch with the knee
extended until the patient experiences pain (over the back & may radiate to the lower limb)
- Distribution of the pain indicating the involved nerve root
- Positive if the angle < 60°- Cross sciatic tension : severe root irritation
(pain on the affected side when raising the unaffected leg)
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2. Sciatic Stretch Test- Following SLR test- Drop the limb about 10° to relieve tension
on the irritated nerve root- Dorsiflex the ankle to reproduce the same
pain
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3. Femoral Stretch Test - For lumbar root
sensitivity- Patient should be
prone- Flex the patient’s knee
and lift the hip into extension
- Pain may be felt in front of the thigh and in the back