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clinical examination of spine

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spine

spine

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  • It is important to have good knowledge of anatomy
    before examining the spine .
  • Spinal cord – foramen magnum to L1
    Conus medullaris – terminal portion of spinal cord
    Filum terminale – fibrous extension of pia mater anchors cord to coccyx
    Cauda equina – collection of nerve roots at the end of vertebral canal
  • Stabbing /shooting – PIVD
    Cont.+ throbbing - osteomylitis
    Intermittent + dull – spondylolisthesis
    Aggravated by mov. /coughing/ sneezing – malignancy
    Night cry + Cont. Dull ache – pott’s spine
  • Transcript

    • 1. CLINICAL EXAMINATION OF SPINE DR. HARDIK S PAWAR Dept. of ORTHOPAEDICS
    • 2. Introduction
    • 3. • • • • • • • 33 vertebrae 31 pairs nerve roots 23 disc Spinal cord – Conus medullaris – Filum terminale – Cauda equina –
    • 4. COMMON CONDITIONS AFFECTING SPINE 1. 2. 3. 4. 5. 6. 7. Congenital - spina bifida Infective - tuberculosis Traumatic - fracture Neoplastic - primary or secondary Metabolic - osteoporosis Degenerative - PIVD , LCS Inflammatory - ankylosing spondylitis
    • 5. Clinical examination
    • 6. Before starting ……. • • • • • Introduce yourself Ask permission to perform examination Explain the patient appropriately – The patient must be exposed properly Tell the patient to let you know if anything you do Is uncomfortable or painful . • When female patient – make sure that female nurse or assistant is present.
    • 7. Clinical examination of spine • • • • • • • History General examination Inspection = look Palpation = feel Movements and measurements Special tests Neurology
    • 8. History … • • • • • • • • • M/F Occupation Socio economic class Presenting chief complaints History of presenting illness Treatment history Past history Personal history Family history
    • 9. History of presenting illness Chief complains : chronological • Pain • Swelling • Weakness/ numbness • Deformity
    • 10. • Pain - site , ODP, severity , cont./intermit., nature , radiation , aggrevating , relieving , positional variation , walking distance
    • 11. • Swelling - site , onset 1st noticed , duration, progression • Deformity - localized / diffuse , duration, progression • Weakness – unilateral / bilateral motor / sensory sudden / insidious duration bowel / bladder involvement - early / late • Restriction of ROM • Difficulty in walking • Any disabilities
    • 12. Ask about . . • • • • • • • • • h/o trauma h/o constitutional symptoms h/o hemoptysis / hemetmesis/malena h/o respirory symptoms , dyspnea h/o other joint involvements h/o pelvic inflammatory disease Treatment history Immunization history BCG , polio. Full developemental history
    • 13. Past history • • • • • • • • Similar complains Prolonged drug history Previous surgery DM HTN Tuberculosis Hematological disorder Any neurological disorder
    • 14. Personal history • • • • • • • Smoking Alcohol Drug addiction Diet Bowel bladder habbit Appetite Menstrual history in Females
    • 15. Family history • Similar illness • Tuberculosis
    • 16. General examination • Head to toe examination weight , height , - neurocutaneous markers – café au lait, hairy patch - ligament laxity - clubbing , cyanosis, palllor - lymphaedenopathy -
    • 17. Local examination start with standing then lying down Inspection • Gait 1. 2. 3. 4. 5. 6. shuffling gait – post cord synd. High stepping gait . alderman’s gait antalgic gait heel walking - L5 . Toe walking – S1
    • 18. • Attitude , deformity
    • 19. Inspection Posteriorly Position of head Level of hair line Length of neck Level of shoulders Level of scapulae Deformity – scoliosis Margin of trunk Spinous processes Iliac crest Dimple of venous
    • 20. Paraspinal muscle spasm or not Any swelling- lipoma cold abscess Renal angle Skin- dimple; hair tufts; nevus; scar; sinus;bed sores café-au- lait spots Step Abnormal trunk furrows Apparent shortening of lower limbs Pelvic obliquity
    • 21. Muscle wasting
    • 22. Laterally   Spinal curves Kyphosis Knuckle Angular Rounded Lordosis Increased decreased Anterilorly Level of nipples Chest shape pectus carrinatum ; excavatum Rib hump Abdomen protution
    • 23. PALPATION Local rise in temperature Palpate all spinous process Prominent spinous process and its significance. Tenderness ( occiput to coccyx) Direct pressure Twist tenderness Deep thrust tenderness Anvil test
    • 24. Structure Landmark Cervical vertebral bodies Same level as spinous processes C1 transverse process One finger’s breadth inferior to mastoid process C3-C4 vertebrae • . C4-C5 vertebrae Posterior to hyoid bone C6 vertebrae Posterior to cricoid cartilage; moves during flexion and extension of cervical spine C7 vertebrae Prominent posterior spinous process T1 vertebrae Prominent protrusion inferior to cervical spine T2 vertebrae Posterior from jugular notch of the sternum T3 vertebrae Even with the medial border of the scapular spine T7 vertebrae Even with the inferior angle of the scapula L3 vertebrae Posterior from the umbilicus L4 vertebrae Level with the iliac crest L5 vertebrae Typically demarcated by bilateral dimples, but variable from person to person S2 At level of the posterior superior iliac spine Posterior to thyroid cartilage
    • 25. Paraspinal muscle spasm/tender Step or deformity – level and no. Any swelling Cold abscess – Site renal angle , petit’s triangle , iliac fossa size Margin Consistensy Fluctuation lymphnodes
    • 26. Sacroiliac joint tenderness
    • 27. MOVEMENTS ( cervical and TL spine ) Flexion Extension Lateral bending Rotation – sitting position
    • 28. Lumbar spine flexion - Forward bending – standing ( finger tip floor distance) 7 cm -
    • 29. Extension - Back ward bending ( angle between axes of lower limb & body) - 15 -20 Lateral flexion ( distance between finger tip & floor) Rotation in sitting position – dorsal spine mainly – 45
    • 30. Cervical spine 1. Flexion - ask the patient to bend the head forwards - chin should be able to touch the chest - normal : 80°
    • 31. 2.Extension - ask the patient to look up and back - normal : 50
    • 32. 3. Lateral flexion - ask the patient to touch his shoulder with the ear - involve atlanto-axial and atlanto-occipital joints - normal : 45
    • 33. 4. Rotation - ask the patient to look over his shoulder - normal : 80° - restricted and painful in cervical spondylitis
    • 34. Segmental mobility Schober`s & modified schober`s test
    • 35. MEASUREMENTS Linear measurements From occipital protrubence to tip of coccyx Iliocostal distance ( tip off last rib to iliac cest) Chest expansion LLD
    • 36. Special tests : Lumbar root tension test : SLRT MODIFIED LASEGUE TEST REVERSE SLRT - FNST FRAJARZTANZ TEST - BRAGGARD SIGN BOWSTRING TEST Well leg SLRT
    • 37. SLRT • • • • • PRE-REQUISITES No exaggerated Lumbar lordosis Normal mobile hip. No FFD at knee joint. No hamstring strain or spasm and contracture. Intelligent and co-operative patient
    • 38. SLRT: Technique • Look at patient face • Ask if the maneuver produces Back pain Leg pain • Radiating pain/ paraesthesias are highly suggestive of Disc prolapse • Measure the angle at which pain just starts appearing. • Normally SLR is possible up to 8090°.
    • 39. SLRT: Technique • If patient cannot lie supine then this is done in lateral position as in severe kyphosis.
    • 40. SLRT: Interpretation Pain •upto 35° is diagnostic of intervertebral disc prolapse. •From 35-70° is suggestive of disc prolapse. •beyond 70° is equivocal.
    • 41. Other Uses of SLRT • Assessing: – stability of hip joint (ACTIVE SLRT). – Integrity of hip flexors. – Quadriceps mechanism of the knee.
    • 42. Fajersztajn test- Braggards sign • Technique: SLRT is done to the point where the symptoms are produced then the limb is slightly lowered and the ankle is dorsiflexed. • If this reproduces the pain then test is considered positive and Braggards sign is present. • It is again highly indicative of prolapsed intervertebral disc and helps differentiate from the other pathologies
    • 43. Modified Lasègue test • With the patient supine, hip and knee are gently flexed to 900 • The knee is then gradually extended which reproduces the symptoms of sciatica. • Helps differentiate from the hip joint pain.
    • 44. REVERSE SLRT • • • • PATIENT PRONE KNEE 90 HIP EXTENDED FEMORAL NERVE ROOTS STRETCHING
    • 45. Cross SLRT • Also known as Well leg raising test or Cross over sign • Technique: – Patient is supine. – Examiner performs a SLR on the patient's unaffected leg to 75º or until it produces pain down the affected leg . • Pathognomic of Disc prolapse • Indicates presence of medial disc
    • 46. BOW STRING TEST • After positive SLRT , the knee is flexed. • Test is positive if the patients pain resolves with flexion at the knee. • Pain may be re-induced without extending the knee by pressing on the lateral popliteal nerve behind the lateral tibial condyle, to tighten it like a bowstring • If pain persists this is suggestive of hip pathology.
    • 47. LHERMITTE’S TEST
    • 48. • NAFZIGER TEST
    • 49. • TEST FOR SI JOINT : • FABER Test [Patrick Test] • Compression Test • Distraction Test • Thigh Thrust Test • Gaenslen’s Test • Pump handle test • Gille’s test
    • 50. NEUROLOGICAL EXAMINATION • • • • HIGHER MENTAL FUNCTION CRANIAL NERVES MOTOR SENSORY
    • 51. MOTOR NEUROLOGY • BULK OF MUSCLES • TONE • MOTOR POWER – MRC GRADING • SENSORY - Superficial , deep • REFLEXES . Superficial : Abdominal T7-T12 Cremastric L1 , L2 Anal S2,3,4 Bulbocavernous s 2,3,4 Planter S 1 Deep : Knee jerk L3 L4 Ankle jerk S1 • CO ORDINATION • INVOLUNTARY MOVEMENTS
    • 52. • UMN Spastic No atrophy Hypertonia DTR increased Superfical reflex altered Babiski sign + LMN Flaccid wasting pronouced Hypotonia absent normal
    • 53. • Sensory : Pain Temperature Light touch Pressure 2 point decrimination joint position vibration
    • 54. Sensation C5 – lateral arm C6 – lateral forearm - thumb & index finger C7 – middle finger C8 – ring&little finger T1 – medial arm
    • 55. Sensation L1 – groin L2 – anterior thigh L3 – anterior knee L4 – leg ant. L5 – lateral leg - medial of foot 1st web space dorsum S1 – lateral of foot dorsum - heel and foot sole S2 – posterior leg and thigh
    • 56. Determining the neural and vertebral level VERTEBRAL • • • • • • • Cervical Thoracic D1 to D6 Thoracic D7 to D9 D10 D11 D12 L1 NEURAL - Add 1 - add 2 - add 3 - L1 , L2 - L3 , L4 - L5 - SACRAL SEGMENTS
    • 57. THANK YOU