Spine Examination And Scoliosis


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Spine Examination And Scoliosis

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Spine Examination And Scoliosis

  3. 3. INSPECTION (LOOK) <ul><li>GAIT </li></ul><ul><ul><li>Normal walking </li></ul></ul><ul><ul><li>Walking on tip toe (S1) </li></ul></ul><ul><ul><li>Walking on heel (L5) </li></ul></ul>
  4. 4. <ul><li>2. STANDING </li></ul><ul><li>a) anterior </li></ul><ul><li>- attitude of the neck and head </li></ul><ul><li>-torticollis </li></ul><ul><li>- any swelling over anterior aspect of neck </li></ul><ul><li>- wasting of the muscle of thigh </li></ul><ul><li>- lower limbs attitude and deformity </li></ul><ul><li>- skin changes </li></ul><ul><li>-scars or sinuses </li></ul>
  5. 5. <ul><li>b) lateral </li></ul><ul><ul><li>Normal cervical, thoracic and lumbar spine </li></ul></ul><ul><ul><li>Gibbus (acute angulation of spine) </li></ul></ul><ul><ul><li>Kyphosis </li></ul></ul><ul><ul><li>Lordosis </li></ul></ul>
  6. 6. <ul><li>c) posterior </li></ul><ul><ul><li>Scoliosis </li></ul></ul><ul><ul><li>Listing of trunk </li></ul></ul><ul><ul><li>Shoulder tilt </li></ul></ul><ul><ul><li>Pelvic tilt </li></ul></ul><ul><ul><li>Wasting of muscle </li></ul></ul><ul><ul><li>Skin changes over the spine (hair tuft, pigmentation) </li></ul></ul><ul><ul><li>Scar </li></ul></ul><ul><ul><li>Sinus </li></ul></ul><ul><ul><li>Swelling </li></ul></ul>
  7. 7. PALPATION (FEEL) <ul><li>Temperature </li></ul><ul><li>Tenderness –along the spinal process </li></ul><ul><li>Paravertebral muscle spasm </li></ul><ul><li>Step deformity </li></ul><ul><li>Swelling </li></ul>
  8. 8. MOVE <ul><li>CERVICAL SPINE </li></ul><ul><li>Forward flexion </li></ul><ul><ul><li>Normal : 75 to 90 degrees </li></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Normal : 45 degrees </li></ul></ul><ul><li>Right lateral flexion </li></ul><ul><ul><li>Normal : 45 to 60 degrees </li></ul></ul><ul><li>Left lateral flexion </li></ul><ul><ul><li>Normal : 45 to 60 degrees </li></ul></ul><ul><li>Rotation to right </li></ul><ul><ul><li>Normal : 75 degrees </li></ul></ul><ul><li>Rotation to left </li></ul><ul><ul><li>Normal : 75 degrees </li></ul></ul>
  9. 9. <ul><li>Thoracic and lumbar spine </li></ul><ul><li>Forward flexion (Schober’s test) </li></ul><ul><ul><li>Normal : 90 degrees </li></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Normal : 30 degrees </li></ul></ul><ul><li>Lateral flexion to left and right </li></ul><ul><ul><li>Normal : 30 to 45 degrees </li></ul></ul><ul><li>Rotation to left and right </li></ul><ul><ul><li>Normal : 45 degrees </li></ul></ul>
  10. 10. SPECIAL TEST <ul><li>Cervical spine : </li></ul><ul><ul><li>Compression test </li></ul></ul><ul><ul><li>Distraction test </li></ul></ul><ul><ul><li>Valsalva test </li></ul></ul><ul><ul><li>Swallowing test </li></ul></ul><ul><ul><li>Adson test </li></ul></ul>
  11. 11. <ul><li>COMPRESSION TEST </li></ul><ul><li>Press down upon the top of pt’s head </li></ul><ul><li>If there is increase pain in either cervical spine or upper extremity, note its exact distribution. So, we can locate the neurological level </li></ul><ul><li>A narrowing of neural foramen, pressure on the facet joints or muscle spasm can cause increase pain upon compression </li></ul>
  12. 12. <ul><li>DISTRACTION TEST </li></ul><ul><li>Place the open palm of one hand under the pt’s chin, and the other hand is upon occiput </li></ul><ul><li>Then, gradually lift (distract) the head to remove its weight from the neck </li></ul><ul><li>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. </li></ul>
  13. 13. <ul><li>VALSALVA TEST </li></ul><ul><li>Ask pt to hold his breath and bear down as if he were moving his bowels </li></ul><ul><li>Then, ask whether he feels any increase in pain and describe the location </li></ul><ul><li>This test increase intratechal pressure </li></ul><ul><li>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 </li></ul><ul><li>The pain also may radiate to the dermatome distribution of cervical spine pathology </li></ul>
  14. 14. <ul><li>SWALLOWING TEST </li></ul><ul><li>Difficulty or pain upon swallowing can sometimes caused by cervical spine pathology such as : </li></ul><ul><ul><li>Bony protuberance </li></ul></ul><ul><ul><li>Bony osteophytes </li></ul></ul><ul><ul><li>Soft tissue swelling due to hematomas, infection or tumor in ant portion of cervical spine </li></ul></ul>
  15. 15. <ul><li>ADSON TEST </li></ul><ul><li>Pull the arm downwards </li></ul><ul><li>Palpate the radial pulse </li></ul><ul><li>Turn the pt’s head to the same side while feeling the radial pulse </li></ul><ul><li>Fading of the radial pulse indicates positive thoracic outlet obstruction </li></ul>
  16. 16. <ul><li>Thoracic and lumbar spine </li></ul><ul><ul><li>Straight leg raising test </li></ul></ul><ul><ul><li>Sciatic stretch test </li></ul></ul><ul><ul><li>Femoral stretch test </li></ul></ul>
  17. 17. <ul><li>STRAIGHT LEG RAISING TEST </li></ul><ul><li>With the knee extended, passively flex the hip in order to lift the lower limb </li></ul><ul><li>The pt will feel pain over the back and radiating to lower limb. </li></ul><ul><li>Watch the distribution of pain indicating the involved nerve root </li></ul><ul><li>Normally accepted positive if the angle of elevation is <60 degrees </li></ul><ul><li>Cross sciatic tension indicate severe root irritation </li></ul>
  18. 18. <ul><li>SCIATIC STRETCH TEST </li></ul><ul><li>Following the SLR test, drop the limb for about 10 degrees to relieve tension on the irritated nerve root </li></ul><ul><li>Dorsiflex the ankle to reproduce the stretching effect on the nerve root </li></ul><ul><li>This will reproduce the sciatica pain </li></ul>
  19. 19. <ul><li>FEMORAL STRETCH TEST </li></ul><ul><li>look for lumbar root tension </li></ul><ul><li>ask the patient to lie prone </li></ul><ul><li>flex the knee </li></ul><ul><li>lift up the hip into extension </li></ul><ul><li>pain may be felt in front of the thigh and the back </li></ul><ul><li>Done to exclude higher disc prolapsed (rare) </li></ul>
  21. 21. <ul><li>UPPER LIMB </li></ul><ul><li>Tone </li></ul><ul><li>Power </li></ul>Nerve root Test C5 Elbow flexion C6 Wrist extension C7 Wrist flexion C8 Finger flexion T1 Finger abduction
  22. 22. <ul><li>Reflexes </li></ul><ul><ul><li>Biceps (C5-6) </li></ul></ul><ul><ul><li>Brachioradialis </li></ul></ul><ul><ul><li>Triceps (C7-8) </li></ul></ul><ul><li>Sensation </li></ul>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
  23. 23. <ul><li>LOWER LIMBS </li></ul><ul><li>Tone </li></ul><ul><li>Power </li></ul>L1,2 Hip flexion L3,4 Knee extension L4 Dorsiflexion L5 Great toe extension S1,2 Plantarflexion
  24. 24. <ul><li>Reflexes </li></ul><ul><ul><li>Knee jerk (L3-4) </li></ul></ul><ul><ul><li>Ankle jerk (S1-2) </li></ul></ul><ul><ul><li>Babinski’s reflex </li></ul></ul><ul><ul><li>Clonus </li></ul></ul><ul><li>Sensation </li></ul><ul><li>Lower limb </li></ul><ul><li>L1 – groin </li></ul><ul><li>L2 – anterior thigh </li></ul><ul><li>L3 – anterior knee </li></ul><ul><li>L4 – medial aspect of leg </li></ul><ul><li>L5 – lateral aspect of leg </li></ul><ul><li>- dorsal aspect of foot </li></ul><ul><li>S1 – lateral aspect of foot </li></ul><ul><li>S2 – posterior aspect leg and thigh </li></ul><ul><li>S3,S4,S5 – perianal region </li></ul>
  25. 25. SCOLIOSIS
  26. 26. SCOLIOSIS <ul><li>Definition : Lateral curvature of the spine </li></ul><ul><li>2 broad types of deformity are defined: </li></ul><ul><ul><li>Postural scoliosis </li></ul></ul><ul><ul><li>Structural scoliosis </li></ul></ul>
  27. 27. Postural scoliosis <ul><li>The deformity is secondary or compensatory to some condition outside the spine. </li></ul><ul><ul><li>Short leg </li></ul></ul><ul><ul><li>Pelvic tilt due to contracture of the hip </li></ul></ul><ul><ul><li>Local muscle spasm a/w PID may cause a skew back (sciatic scoliosis) </li></ul></ul><ul><ul><li>The curve disappear when the patient sit or on forward flexion. </li></ul></ul>
  28. 28. Structural scoliosis <ul><li>Usually accompanied by bony abnormality or vertebral rotation. </li></ul><ul><li>The deformity is fixed and does not disappear with changes in position. </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Idiopathic (most cases) </li></ul></ul><ul><ul><li>Osteopathic (congenital) </li></ul></ul><ul><ul><li>Neuropathic ( poliomyelitis, cerebral palsy) </li></ul></ul><ul><ul><li>Myopathic ( muscular dystrophies) </li></ul></ul><ul><ul><li>Neurofibromatosis </li></ul></ul>
  29. 29. IDIOPATHIC SCOLIOSIS <ul><li>Constitutes about 80% of all cases of scoliosis </li></ul><ul><li>Age of onset have been used to defined 3 groups: </li></ul><ul><ul><li>Adolescent ( ≥ 10 y/o ) - commonest </li></ul></ul><ul><ul><li>Juvenile ( 4 - 9 y/o ) </li></ul></ul><ul><ul><li>Infantile ( ≤ 3 y/o ) </li></ul></ul>
  30. 30. ADOLESCENT IDIOPATHIC SCOLIOSIS <ul><li>Commonest type </li></ul><ul><li>Occur mostly in girls </li></ul><ul><li>Usually present at the age of 10 – 15 y/o </li></ul>
  31. 31. CLINICAL FEATURES <ul><li>Symptoms: </li></ul><ul><ul><li>Deformity (skew back, rib hump) </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Deviation of the spine from the midline (right thoracic curves are the commonest) </li></ul></ul><ul><ul><li>Does not disappear with flexion </li></ul></ul><ul><ul><li>The hip sticks out on the concave side </li></ul></ul><ul><ul><li>Breast and shoulder may be asymmetrical </li></ul></ul><ul><ul><li>Asymmetrical rib hump on the convex side (thoracic scoliosis) </li></ul></ul>
  32. 33. X-RAY <ul><li>Full length PA and lateral view of the spine and iliac crest must be taken with the patient erect. </li></ul><ul><li>Angle of curvature is measured (Cobb’s </li></ul><ul><li>angle) </li></ul>
  33. 34. X-RAY <ul><li>Risser’s sign is identified. </li></ul><ul><li>(skeletal maturity) </li></ul>
  34. 35. TREATMENT <ul><li>Conservative treatment </li></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><ul><li>Have no effect on the curve but help to maintain muscle tone </li></ul></ul></ul><ul><ul><ul><ul><li>Bracing </li></ul></ul></ul></ul><ul><ul><ul><li>Is used for </li></ul></ul></ul><ul><ul><ul><ul><li>All progressive curves over 20⁰ but less than 40⁰ </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Well balanced double curve </li></ul></ul></ul></ul><ul><ul><ul><ul><li>With younger children needing operation, to hold the curve stationary until they reach adolescence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>To prevent recurrence after spinal fusion </li></ul></ul></ul></ul>
  35. 36. Boston brace Milwaukee brace
  36. 37. <ul><li>Operative treatment </li></ul><ul><ul><li>Indicated for curves > 40⁰ </li></ul></ul><ul><ul><li>Type of surgery: </li></ul></ul><ul><ul><ul><li>The Harrington system </li></ul></ul></ul><ul><ul><ul><li>Rod and sublaminar wiring </li></ul></ul></ul><ul><ul><ul><li>Posterior or anterior instrumentation </li></ul></ul></ul>
  37. 38. THANK YOU