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CLINICAL
EXAMINATION OF
SPINE
DR. HARDIK S PAWAR
Dept. of ORTHOPAEDICS
Introduction
•
•
•
•
•
•
•

33 vertebrae
31 pairs nerve roots
23 disc
Spinal cord –
Conus medullaris –
Filum terminale –
Cauda equina –
COMMON CONDITIONS AFFECTING
SPINE
1.
2.
3.
4.
5.
6.
7.

Congenital - spina bifida
Infective
- tuberculosis
Traumatic - fra...
Clinical examination
Before starting …….
•
•
•
•
•

Introduce yourself
Ask permission to perform examination
Explain the patient appropriately ...
Clinical examination of spine
•
•
•
•
•
•
•

History
General examination
Inspection = look
Palpation = feel
Movements and ...
History …
•
•
•
•
•
•
•
•
•

M/F
Occupation
Socio economic class
Presenting chief complaints
History of presenting illness...
History of presenting illness
Chief complains : chronological
• Pain
• Swelling
• Weakness/ numbness
• Deformity
• Pain - site ,
ODP,
severity ,
cont./intermit.,
nature ,
radiation ,
aggrevating ,
relieving ,
positional variation ,
wal...
• Swelling - site , onset 1st noticed , duration, progression
• Deformity - localized / diffuse , duration, progression
• ...
Ask about . .
•
•
•
•
•
•
•
•
•

h/o trauma
h/o constitutional symptoms
h/o hemoptysis / hemetmesis/malena
h/o respirory s...
Past history
•
•
•
•
•
•
•
•

Similar complains
Prolonged drug history
Previous surgery
DM
HTN
Tuberculosis
Hematological ...
Personal history
•
•
•
•
•
•
•

Smoking
Alcohol
Drug addiction
Diet
Bowel bladder habbit
Appetite
Menstrual history in Fem...
Family history
• Similar illness
• Tuberculosis
General examination
• Head to toe examination
weight , height ,
- neurocutaneous markers – café au lait,
hairy patch
- lig...
Local examination
start with standing then lying down

Inspection
• Gait
1.
2.
3.
4.
5.
6.

shuffling gait – post cord syn...
• Attitude , deformity
Inspection
Posteriorly
Position of head
Level of hair line
Length of neck
Level of shoulders
Level of scapulae
Deformity –...
Paraspinal muscle spasm or not
Any swelling- lipoma
cold abscess Renal angle
Skin- dimple; hair tufts; nevus; scar; sinus;...
Muscle wasting
Laterally
 
Spinal curves
Kyphosis
Knuckle
Angular
Rounded
Lordosis
Increased
decreased
Anterilorly
Level of nipples
Chest...
PALPATION

Local rise in temperature
Palpate all spinous process
Prominent spinous process
and its significance.
Tendernes...
Structure

Landmark

Cervical vertebral bodies

Same level as spinous processes

C1 transverse process

One finger’s bread...
Paraspinal muscle spasm/tender
Step or deformity – level and no.
Any swelling
Cold abscess –
Site
renal angle ,
petit’s tr...
Sacroiliac joint tenderness
MOVEMENTS
( cervical and TL spine )
Flexion
Extension
Lateral bending
Rotation – sitting position
Lumbar spine
flexion - Forward bending – standing ( finger tip floor distance) 7 cm
-
Extension - Back ward bending ( angle between axes of lower limb &
body) - 15 -20
Lateral flexion ( distance between finge...
Cervical spine
1. Flexion
- ask the patient
to bend the head forwards
- chin should be
able to touch the chest
- normal : ...
2.Extension
- ask the patient to look
up and back
- normal : 50
3. Lateral flexion
- ask the patient
to touch his shoulder with the ear
- involve atlanto-axial
and atlanto-occipital join...
4. Rotation
- ask the patient to look
over his shoulder
- normal : 80°
- restricted and painful
in cervical spondylitis
Segmental mobility
Schober`s & modified schober`s test
MEASUREMENTS
Linear measurements
From occipital protrubence to tip of coccyx
Iliocostal distance ( tip off last rib to ili...
Special tests :
Lumbar root tension test :
SLRT
MODIFIED LASEGUE TEST
REVERSE SLRT - FNST
FRAJARZTANZ TEST - BRAGGARD SIGN...
SLRT

•
•
•
•
•

PRE-REQUISITES
No exaggerated Lumbar lordosis
Normal mobile hip.
No FFD at knee joint.
No hamstring strai...
SLRT: Technique
• Look at patient face
• Ask if the maneuver produces
Back pain
Leg pain

• Radiating pain/ paraesthesia...
SLRT: Technique
• If patient cannot lie supine then
this is done in lateral position
as in severe kyphosis.
SLRT: Interpretation
Pain
•upto 35° is diagnostic of
intervertebral disc prolapse.
•From 35-70° is suggestive of
disc prol...
Other Uses of SLRT

• Assessing:
– stability of hip joint (ACTIVE SLRT).
– Integrity of hip flexors.
– Quadriceps mechanis...
Fajersztajn test- Braggards
sign
• Technique: SLRT is done to the point
where the symptoms are produced then
the limb is s...
Modified Lasègue test
• With the patient supine, hip and
knee are gently flexed to 900
• The knee is then gradually
extend...
REVERSE SLRT
•
•
•
•

PATIENT PRONE
KNEE 90
HIP EXTENDED
FEMORAL NERVE ROOTS STRETCHING
Cross SLRT
• Also known as Well leg raising test or
Cross over sign
• Technique:
– Patient is supine.
– Examiner performs ...
BOW STRING TEST
• After positive SLRT , the knee is flexed.
• Test is positive if the patients pain resolves
with flexion ...
LHERMITTE’S TEST
• NAFZIGER TEST
• TEST FOR SI JOINT :
• FABER Test [Patrick Test]
• Compression Test
• Distraction Test
•

Thigh Thrust Test

• Gaenslen’s...
NEUROLOGICAL EXAMINATION
•
•
•
•

HIGHER MENTAL FUNCTION
CRANIAL NERVES
MOTOR
SENSORY
MOTOR NEUROLOGY
• BULK OF MUSCLES
• TONE
• MOTOR POWER – MRC GRADING
• SENSORY - Superficial , deep
• REFLEXES .
Superfici...
• UMN
Spastic
No atrophy
Hypertonia
DTR increased
Superfical reflex altered
Babiski sign +

LMN
Flaccid
wasting pronouced
...
• Sensory :
Pain
Temperature
Light touch
Pressure
2 point decrimination
joint position
vibration
Sensation
C5 – lateral arm
C6 – lateral forearm
- thumb & index finger
C7 – middle finger
C8 – ring&little finger
T1 – med...
Sensation
L1 – groin
L2 – anterior thigh
L3 – anterior knee
L4 – leg ant.
L5 – lateral leg
- medial of foot 1st web space
...
Determining the neural and
vertebral level
VERTEBRAL
•
•
•
•
•
•
•

Cervical
Thoracic D1 to D6
Thoracic D7 to D9
D10
D11
D...
THANK YOU
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
clinical examination of spine
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clinical examination of spine

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clinical examination of spine

  1. 1. CLINICAL EXAMINATION OF SPINE DR. HARDIK S PAWAR Dept. of ORTHOPAEDICS
  2. 2. Introduction
  3. 3. • • • • • • • 33 vertebrae 31 pairs nerve roots 23 disc Spinal cord – Conus medullaris – Filum terminale – Cauda equina –
  4. 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. 5. Clinical examination
  6. 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. 7. Clinical examination of spine • • • • • • • History General examination Inspection = look Palpation = feel Movements and measurements Special tests Neurology
  8. 8. History … • • • • • • • • • M/F Occupation Socio economic class Presenting chief complaints History of presenting illness Treatment history Past history Personal history Family history
  9. 9. History of presenting illness Chief complains : chronological • Pain • Swelling • Weakness/ numbness • Deformity
  10. 10. • Pain - site , ODP, severity , cont./intermit., nature , radiation , aggrevating , relieving , positional variation , walking distance
  11. 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. 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. 13. Past history • • • • • • • • Similar complains Prolonged drug history Previous surgery DM HTN Tuberculosis Hematological disorder Any neurological disorder
  14. 14. Personal history • • • • • • • Smoking Alcohol Drug addiction Diet Bowel bladder habbit Appetite Menstrual history in Females
  15. 15. Family history • Similar illness • Tuberculosis
  16. 16. General examination • Head to toe examination weight , height , - neurocutaneous markers – café au lait, hairy patch - ligament laxity - clubbing , cyanosis, palllor - lymphaedenopathy -
  17. 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. 18. • Attitude , deformity
  19. 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. 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. 21. Muscle wasting
  22. 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. 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. 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. 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. 26. Sacroiliac joint tenderness
  27. 27. MOVEMENTS ( cervical and TL spine ) Flexion Extension Lateral bending Rotation – sitting position
  28. 28. Lumbar spine flexion - Forward bending – standing ( finger tip floor distance) 7 cm -
  29. 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. 30. Cervical spine 1. Flexion - ask the patient to bend the head forwards - chin should be able to touch the chest - normal : 80°
  31. 31. 2.Extension - ask the patient to look up and back - normal : 50
  32. 32. 3. Lateral flexion - ask the patient to touch his shoulder with the ear - involve atlanto-axial and atlanto-occipital joints - normal : 45
  33. 33. 4. Rotation - ask the patient to look over his shoulder - normal : 80° - restricted and painful in cervical spondylitis
  34. 34. Segmental mobility Schober`s & modified schober`s test
  35. 35. MEASUREMENTS Linear measurements From occipital protrubence to tip of coccyx Iliocostal distance ( tip off last rib to iliac cest) Chest expansion LLD
  36. 36. Special tests : Lumbar root tension test : SLRT MODIFIED LASEGUE TEST REVERSE SLRT - FNST FRAJARZTANZ TEST - BRAGGARD SIGN BOWSTRING TEST Well leg SLRT
  37. 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. 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. 39. SLRT: Technique • If patient cannot lie supine then this is done in lateral position as in severe kyphosis.
  40. 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. 41. Other Uses of SLRT • Assessing: – stability of hip joint (ACTIVE SLRT). – Integrity of hip flexors. – Quadriceps mechanism of the knee.
  42. 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. 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. 44. REVERSE SLRT • • • • PATIENT PRONE KNEE 90 HIP EXTENDED FEMORAL NERVE ROOTS STRETCHING
  45. 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. 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. 47. LHERMITTE’S TEST
  48. 48. • NAFZIGER TEST
  49. 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. 50. NEUROLOGICAL EXAMINATION • • • • HIGHER MENTAL FUNCTION CRANIAL NERVES MOTOR SENSORY
  51. 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. 52. • UMN Spastic No atrophy Hypertonia DTR increased Superfical reflex altered Babiski sign + LMN Flaccid wasting pronouced Hypotonia absent normal
  53. 53. • Sensory : Pain Temperature Light touch Pressure 2 point decrimination joint position vibration
  54. 54. Sensation C5 – lateral arm C6 – lateral forearm - thumb & index finger C7 – middle finger C8 – ring&little finger T1 – medial arm
  55. 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. 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. 57. THANK YOU

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