SPINE EXAMINATION AND SCOLIOSIS

SPINE EXAMINATION

INSPECTION (LOOK) GAIT Normal walking Walking on tip toe (S1) Walking on heel (L5)

GAIT

Normal walking

Walking on tip toe (S1)

Walking on heel (L5)

2. STANDING a) anterior - attitude of the neck and head -torticollis - any swelling over anterior aspect of neck - wasting of the muscle of thigh - lower limbs attitude and deformity - skin changes -scars or sinuses

2. STANDING

a) anterior

- attitude of the neck and head

-torticollis

- any swelling over anterior aspect of neck

- wasting of the muscle of thigh

- lower limbs attitude and deformity

- skin changes

-scars or sinuses

b) lateral Normal cervical, thoracic and lumbar spine Gibbus (acute angulation of spine) Kyphosis Lordosis

b) lateral

Normal cervical, thoracic and lumbar spine

Gibbus (acute angulation of spine)

Kyphosis

Lordosis

c) posterior Scoliosis Listing of trunk Shoulder tilt Pelvic tilt Wasting of muscle Skin changes over the spine (hair tuft, pigmentation) Scar Sinus Swelling

c) posterior

Scoliosis

Listing of trunk

Shoulder tilt

Pelvic tilt

Wasting of muscle

Skin changes over the spine (hair tuft, pigmentation)

Scar

Sinus

Swelling

PALPATION (FEEL) Temperature Tenderness –along the spinal process Paravertebral muscle spasm Step deformity Swelling

Temperature

Tenderness –along the spinal process

Paravertebral muscle spasm

Step deformity

Swelling

MOVE CERVICAL SPINE Forward flexion Normal : 75 to 90 degrees Extension Normal : 45 degrees Right lateral flexion Normal : 45 to 60 degrees Left lateral flexion Normal : 45 to 60 degrees Rotation to right Normal : 75 degrees Rotation to left Normal : 75 degrees

CERVICAL SPINE

Forward flexion

Normal : 75 to 90 degrees

Extension

Normal : 45 degrees

Right lateral flexion

Normal : 45 to 60 degrees

Left lateral flexion

Normal : 45 to 60 degrees

Rotation to right

Normal : 75 degrees

Rotation to left

Normal : 75 degrees

Thoracic and lumbar spine Forward flexion (Schober’s test) Normal : 90 degrees Extension Normal : 30 degrees Lateral flexion to left and right Normal : 30 to 45 degrees Rotation to left and right Normal : 45 degrees

Thoracic and lumbar spine

Forward flexion (Schober’s test)

Normal : 90 degrees

Extension

Normal : 30 degrees

Lateral flexion to left and right

Normal : 30 to 45 degrees

Rotation to left and right

Normal : 45 degrees

SPECIAL TEST Cervical spine : Compression test Distraction test Valsalva test Swallowing test Adson test

Cervical spine :

Compression test

Distraction test

Valsalva test

Swallowing test

Adson test

COMPRESSION TEST Press down upon the top of pt’s head If there is increase pain in either cervical spine or upper extremity, note its exact distribution. So, we can locate the neurological level A narrowing of neural foramen, pressure on the facet joints or muscle spasm can cause increase pain upon compression

COMPRESSION TEST

Press down upon the top of pt’s head

If there is increase pain in either cervical spine or upper extremity, note its exact distribution. So, we can locate the neurological level

A narrowing of neural foramen, pressure on the facet joints or muscle spasm can cause increase pain upon compression

DISTRACTION TEST Place the open palm of one hand under the pt’s chin, and the other hand is upon occiput Then, gradually lift (distract) the head to remove its weight from the neck To demonstrate the effect that neck traction might have help in relieving the pain by decreasing pressure on the joint capsules around the facet joints.

DISTRACTION TEST

Place the open palm of one hand under the pt’s chin, and the other hand is upon occiput

Then, gradually lift (distract) the head to remove its weight from the neck

To demonstrate the effect that neck traction might have help in relieving the pain by decreasing pressure on the joint capsules around the facet joints.

VALSALVA TEST Ask pt to hold his breath and bear down as if he were moving his bowels Then, ask whether he feels any increase in pain and describe the location This test increase intratechal pressure If a space occupying lesion, such as a herniated disc or a tumor present in cervical canal, pt may develop pain in cervical spine secondary to increase pressure The pain also may radiate to the dermatome distribution of cervical spine pathology

VALSALVA TEST

Ask pt to hold his breath and bear down as if he were moving his bowels

Then, ask whether he feels any increase in pain and describe the location

This test increase intratechal pressure

If a space occupying lesion, such as a herniated disc or a tumor present in cervical canal, pt may develop pain in cervical spine secondary to increase pressure

The pain also may radiate to the dermatome distribution of cervical spine pathology

SWALLOWING TEST Difficulty or pain upon swallowing can sometimes caused by cervical spine pathology such as : Bony protuberance Bony osteophytes Soft tissue swelling due to hematomas, infection or tumor in ant portion of cervical spine

SWALLOWING TEST

Difficulty or pain upon swallowing can sometimes caused by cervical spine pathology such as :

Bony protuberance

Bony osteophytes

Soft tissue swelling due to hematomas, infection or tumor in ant portion of cervical spine

ADSON TEST Pull the arm downwards Palpate the radial pulse Turn the pt’s head to the same side while feeling the radial pulse Fading of the radial pulse indicates positive thoracic outlet obstruction

ADSON TEST

Pull the arm downwards

Palpate the radial pulse

Turn the pt’s head to the same side while feeling the radial pulse

Fading of the radial pulse indicates positive thoracic outlet obstruction

Thoracic and lumbar spine Straight leg raising test Sciatic stretch test Femoral stretch test

Thoracic and lumbar spine

Straight leg raising test

Sciatic stretch test

Femoral stretch test

STRAIGHT LEG RAISING TEST With the knee extended, passively flex the hip in order to lift the lower limb The pt will feel pain over the back and radiating to lower limb. Watch the distribution of pain indicating the involved nerve root Normally accepted positive if the angle of elevation is <60 degrees Cross sciatic tension indicate severe root irritation

STRAIGHT LEG RAISING TEST

With the knee extended, passively flex the hip in order to lift the lower limb

The pt will feel pain over the back and radiating to lower limb.

Watch the distribution of pain indicating the involved nerve root

Normally accepted positive if the angle of elevation is <60 degrees

Cross sciatic tension indicate severe root irritation

SCIATIC STRETCH TEST Following the SLR test, drop the limb for about 10 degrees to relieve tension on the irritated nerve root Dorsiflex the ankle to reproduce the stretching effect on the nerve root This will reproduce the sciatica pain

SCIATIC STRETCH TEST

Following the SLR test, drop the limb for about 10 degrees to relieve tension on the irritated nerve root

Dorsiflex the ankle to reproduce the stretching effect on the nerve root

This will reproduce the sciatica pain

FEMORAL STRETCH TEST look for lumbar root tension ask the patient to lie prone flex the knee lift up the hip into extension pain may be felt in front of the thigh and the back Done to exclude higher disc prolapsed (rare)

FEMORAL STRETCH TEST

look for lumbar root tension

ask the patient to lie prone

flex the knee

lift up the hip into extension

pain may be felt in front of the thigh and the back

Done to exclude higher disc prolapsed (rare)

NEUROLOGICAL EXAMINATION

UPPER LIMB Tone Power Nerve root Test C5 Elbow flexion C6 Wrist extension C7 Wrist flexion C8 Finger flexion T1 Finger abduction

UPPER LIMB

Tone

Power

Reflexes Biceps (C5-6) Brachioradialis Triceps (C7-8) Sensation Upper limb C5 - lateral forearm C6 - lateral forearm - thumb and index finger C7 - middle finger C8 - ring and little fingers - medial forearm T1 - medial elbow - distal half of the medial arm T2 - proximal half of medial arm

Reflexes

Biceps (C5-6)

Brachioradialis

Triceps (C7-8)

Sensation

LOWER LIMBS Tone Power L1,2 Hip flexion L3,4 Knee extension L4 Dorsiflexion L5 Great toe extension S1,2 Plantarflexion

LOWER LIMBS

Tone

Power

Reflexes Knee jerk (L3-4) Ankle jerk (S1-2) Babinski’s reflex Clonus Sensation Lower limb L1 – groin L2 – anterior thigh L3 – anterior knee L4 – medial aspect of leg L5 – lateral aspect of leg - dorsal aspect of foot S1 – lateral aspect of foot S2 – posterior aspect leg and thigh S3,S4,S5 – perianal region

Reflexes

Knee jerk (L3-4)

Ankle jerk (S1-2)

Babinski’s reflex

Clonus

Sensation

Lower limb

L1 – groin

L2 – anterior thigh

L3 – anterior knee

L4 – medial aspect of leg

L5 – lateral aspect of leg

- dorsal aspect of foot

S1 – lateral aspect of foot

S2 – posterior aspect leg and thigh

S3,S4,S5 – perianal region

SCOLIOSIS

SCOLIOSIS Definition : Lateral curvature of the spine 2 broad types of deformity are defined: Postural scoliosis Structural scoliosis

Definition : Lateral curvature of the spine

2 broad types of deformity are defined:

Postural scoliosis

Structural scoliosis

Postural scoliosis The deformity is secondary or compensatory to some condition outside the spine. Short leg Pelvic tilt due to contracture of the hip Local muscle spasm a/w PID may cause a skew back (sciatic scoliosis) The curve disappear when the patient sit or on forward flexion.

The deformity is secondary or compensatory to some condition outside the spine.

Short leg

Pelvic tilt due to contracture of the hip

Local muscle spasm a/w PID may cause a skew back (sciatic scoliosis)

The curve disappear when the patient sit or on forward flexion.

Structural scoliosis Usually accompanied by bony abnormality or vertebral rotation. The deformity is fixed and does not disappear with changes in position. Causes: Idiopathic (most cases) Osteopathic (congenital) Neuropathic ( poliomyelitis, cerebral palsy) Myopathic ( muscular dystrophies) Neurofibromatosis

Usually accompanied by bony abnormality or vertebral rotation.

The deformity is fixed and does not disappear with changes in position.

Causes:

Idiopathic (most cases)

Osteopathic (congenital)

Neuropathic ( poliomyelitis, cerebral palsy)

Myopathic ( muscular dystrophies)

Neurofibromatosis

IDIOPATHIC SCOLIOSIS Constitutes about 80% of all cases of scoliosis Age of onset have been used to defined 3 groups: Adolescent ( ≥ 10 y/o ) - commonest Juvenile ( 4 - 9 y/o ) Infantile ( ≤ 3 y/o )

Constitutes about 80% of all cases of scoliosis

Age of onset have been used to defined 3 groups:

Adolescent ( ≥ 10 y/o ) - commonest

Juvenile ( 4 - 9 y/o )

Infantile ( ≤ 3 y/o )

ADOLESCENT IDIOPATHIC SCOLIOSIS Commonest type Occur mostly in girls Usually present at the age of 10 – 15 y/o

Commonest type

Occur mostly in girls

Usually present at the age of 10 – 15 y/o

CLINICAL FEATURES Symptoms: Deformity (skew back, rib hump) Signs: Deviation of the spine from the midline (right thoracic curves are the commonest) Does not disappear with flexion The hip sticks out on the concave side Breast and shoulder may be asymmetrical Asymmetrical rib hump on the convex side (thoracic scoliosis)

Symptoms:

Deformity (skew back, rib hump)

Signs:

Deviation of the spine from the midline (right thoracic curves are the commonest)

Does not disappear with flexion

The hip sticks out on the concave side

Breast and shoulder may be asymmetrical

Asymmetrical rib hump on the convex side (thoracic scoliosis)

X-RAY Full length PA and lateral view of the spine and iliac crest must be taken with the patient erect. Angle of curvature is measured (Cobb’s angle)

Full length PA and lateral view of the spine and iliac crest must be taken with the patient erect.

Angle of curvature is measured (Cobb’s

angle)

X-RAY Risser’s sign is identified. (skeletal maturity)

Risser’s sign is identified.

(skeletal maturity)

TREATMENT Conservative treatment Exercise Have no effect on the curve but help to maintain muscle tone Bracing Is used for All progressive curves over 20⁰ but less than 40⁰ Well balanced double curve With younger children needing operation, to hold the curve stationary until they reach adolescence To prevent recurrence after spinal fusion

Conservative treatment

Exercise

Have no effect on the curve but help to maintain muscle tone

Bracing

Is used for

All progressive curves over 20⁰ but less than 40⁰

Well balanced double curve

With younger children needing operation, to hold the curve stationary until they reach adolescence

To prevent recurrence after spinal fusion

Boston brace Milwaukee brace

Operative treatment Indicated for curves > 40⁰ Type of surgery: The Harrington system Rod and sublaminar wiring Posterior or anterior instrumentation

Operative treatment

Indicated for curves > 40⁰

Type of surgery:

The Harrington system

Rod and sublaminar wiring

Posterior or anterior instrumentation

THANK YOU