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Examination of spine

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  • 1. Examination of SPINE
  • 2. Exposure
    • Clothed only in underpants
  • Look
    Gait
    • Normal walking
    • 3. wide base gait – cervical myelopathy
    • 4. waddling gait – proximal myopathy
    • 5. Walking on tip toe – S1 weakness
    • 6. Walking on heels – L5 weakness
  • 2. Standing
    Look from the side
    i. normal spine
    > cervical lordosis
    > thoracic kyphosis
    > lumbar lordosis
  • 7. 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
  • 8. iii. Gibbus (angular kyphosis)
    > fracture
    > tuberculosis of the spine
    > congenital abnormality
  • 9. 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
  • 10. (b) Look from behind
    i. 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 tilt
    iv. Pelvic tilt
  • 11. v. Skin changes over the spine
    - hair tuft (spina bifida)
    - sinus
    - colour changes or pigmentation (neurofibroma)
    - scar
    vi. Swelling
    vii. Prominent crease of the trunk
    viii. Wasting of glutei, hamstrings and calf muscles
  • 12. Feel
    • along the spinous process, looking for tenderness
    • 13. paravertebral muscle spasm
    • 14. sacro-iliac joint tenderness
    • 15. step deformity (spondylolisthesis)
    • 16. Slide the fingers down the lumbar spine on to the sacrum
    • 17. A palpable step at the lumbo-sacral junction
  • 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
  • 18. Lumbar spine excursion test (Schober’s method)
    • Mark 2 points 10cm apart at the midline of lumbar spine
    • 19. Anchor the top of the tape with a finger and ask the patient to flex as far as he can
    • 20. Measure the increase in the distance between the 2 points which indicate lumbar excursion
    • 21. Normal excursion = 5 cm or more
  • .
    .
  • 22. 2. Extension
    - ask the patient to arch his back
    - assist him by steadying the pelvis and pulling back on the shoulder
    - normal : 30°
  • 23. 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°
  • 24. 4. Rotation
    - patient seated to fix the pelvis or pelvis fixed by examiner
    - ask the patient to twist round to each side
    - normal : 45°
  • 25. Cervical spine
    Flexion
    - ask the patient to bend the head forwards
    - chin should be able to touch the chest
    - normal : 80°
  • 26. 2.Extension
    - ask the patient to look up and back
    - normal : 50°
  • 27. 3. Lateral flexion
    - ask the patient to touch his shoulder with the ear
    - involve atlanto-axial and atlanto-occipital joints
    - normal : 45°
  • 28. 4. Rotation
    - ask the patient to look over his shoulder
    - normal : 80°
    - restricted and painful in cervical spondylitis
  • 29. Neurological Examination
    UPPER LIMB
    Tone
    • hypertonia : UMNL
    • 30. normotonia
    • 31. hypotonia : LMNL
  • 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
  • 32. iv. Fingers
    - flexion : C7,C8
    - extension : C7,C8
    - abduction : C8,T1
    - adduction : C8,T1
  • 33. 3. Reflex
    - biceps jerk : C5,C6
    - triceps jerk : C7,C8
    - brachioradialis (supinator) jerk : C5,C6
  • 34. 4. Sensation
    C5 – lateral arm
    C6 – lateral forearm
    - thumb & index finger
    C7 – middle finger
    C8 – ring&little finger
    T1 – medial arm
  • 35. LOWER LIMB
    Tone
    • hypertonia : UMNL
    • 36. normotonia
    • 37. hypotonia : LMNL
  • 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
  • 38. iii. Ankle
    - plantar flexion : S1,S2
    - dorsiflexion : L4,L5
    iv. Tarsal joint
    - eversion : L5,S1
    - inversion : L5,S1
  • 39. 3. Reflex
    - knee jerk : L3,L4
    - ankle jerk : S1,S2
    - plantar reflex : L5,S1,S2
  • 40. 4. Sensation
    L1 – groin
    L2 – anterior thigh
    L3 – anterior knee
    L4 – medial leg
    L5 – lateral leg
    - medial of foot dorsum
    S1 – lateral of foot dorsum
    - heel and foot sole
    S2 – posterior leg and thigh
  • 41. Special Tests
    Straight leg raising test
    • do on normal limb 1st
    • 42. raise the leg from the couch with the knee extended until the patient experiences pain (over the back & may radiate to the lower limb)
    • 43. Distribution of the pain indicating the involved nerve root
    • 44. Positive if the angle < 60°
    • 45. Cross sciatic tension : severe root irritation
    (pain on the affected side when raising the unaffected leg)
  • 46. 2. Sciatic Stretch Test
    • Following SLR test
    • 47. Drop the limb about 10° to relieve tension on the irritated nerve root
    • 48. Dorsiflex the ankle to reproduce the same pain
  • 3. Femoral Stretch Test
    • For lumbar root sensitivity
    • 49. Patient should be prone
    • 50. Flex the patient’s knee and lift the hip into extension
    • 51. Pain may be felt in front of the thigh and in the back

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