Examination of spine

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Examination of spine

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

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