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Spine examination-Part 2
- 1. SPINE EXAMINATION CHECKLIST (PART II :THE NEUROLOGICAL EXAMINATION) PRESENTOR: DR ARCHIT JAIN (UCMS & GTB HOSPITAL,DELHI)
- 2. NEUROLOGICAL EXAMINATION TheVertebral level The pathological process : Extradural or Intradural The extent of deficit: The Neurological level The type of deficit: UMN or LMN
- 4. Symptoms/Sign EXTRA-DURAL INTRA-DURAL (Extramedullary) INTRA-DURAL (Intramedullary) ) Vertebral Column deformity + - - Radiculopathy + + - Motor/Sensory Loss B/L Symmetrical U/L to begin with B/L Symmetrical Bladder/Bowel LATE EARLY EARLY Vertebral Pain + - - Trophic changes LATE LATE EARLY EXAMPLES Pott’s Spine PIVD Metastases Meningioma Neurofibroma AV Malformations Ependymoma Chordoma Lipoma
- 5. Relationship between Vertebral level & Spinal segment VERTEBRAL LEVEL C – spine T1 -T6 T7 -T9 T10 T11 T12 L1 NEURAL LEVEL +1 +2 +3 L1 - L2 L3 – L4 L 5 Sacral segments
- 6. NEURO- LOGICAL EXAM- INATION Higher Mental Function Cranial Nerves Function Motor Sensory Autonomous
- 7. Higher Mental Functions Conscious Oriented toTIME PLACE & PERSON Responsive to commands
- 8. Cranial Nerve Functions 12 pairs of cranial nerves
- 9. MOTOR EXAMINATION BULK TONE POWER REFLEXES
- 10. NEUROLOGICAL EXAMINATION > MOTOR > BULK Estimated on Inspection Confirmed on Palpation Arm 4” above oleacranon Thigh 7” above patella Leg4” below tibial tuberosity RESULTS Atrophy (“Wasting”) Hypertrophy
- 11. NEUROLOGICAL EXAMINATION > MOTOR > TONE Contracted state of muscles at rest (result of local reflex arc) Ask the patient to keep their legs fully relaxed and “floppy” throughout your assessment. METHODS: Passive movements - at all major joints (wrist /elbow/shoulder) Leg roll – roll the patient’s leg & watch the foot – it should flop independently of the leg Leg lift – briskly lift leg off the bed at the knee joint – the heel should remain in contact with the bed
- 13. NEUROLOGICAL EXAMINATION > MOTOR > TONE Flaccidity/hypotonia -LMN Lesions Hypertonia (Rigidity) -Clasp knife -Cog wheel
- 14. Increased tone (Hypertonia) CLASP KNIFE RIGIDITY (SPASTICITY) Initial resistance --- Give way UMN lesions (Cortico-spinal tracts) COG-WHEEL RIGIDITY Tone alternatively increases and decreases Extrapyramidal diseases (Parkinsonism)
- 15. NEUROLOGICAL EXAMINATION > MOTOR > POWER Assess one side at a time and compare like for like. MRC Grading
- 17. NEUROLOGICAL EXAMINATION > MOTOR > POWER : Assessment UPPER LIMB NEUROLOGY LOWER LIMB NEUROLOGY
- 19. REFLEXARC
- 20. DIFFERENCE SUPERFICIAL REFLEX Elicited by stimulating superficial structures like skin, mucous membrane, cornea Polysynaptic reflex Mechanism includes Corticospinal tract Lost in UMN lesions DEEP REFLEX Elicited by stimulating deeper strucutures beneath the skin like tendons Aka tendon reflex Monosynaptic reflexes Does not include CST May be intact
- 23. DEEP REFLEXES
- 24. NEUROLOGICAL EXAMINATION > MOTOR > REFLEXES> CLONUS State of exaggerated deep tendon reflex repetitive contractions of muscles being tested occur after single stimulus ANKLE CLONUS PATELLAR CLONUS • Unsustained clonus (≤5 beats): may be physiological • Sustained clonus (>5 beats): regarded as abnormal
- 26. NEUROLOGICAL EXAMINATION > MOTOR > REFLEXES> REINFORCEMENT For upper limbs: Clench teeth/ Clench fist For lower limb: Jendrassik’s manoeuvre
- 27. NEUROLOGICAL EXAMINATION > MOTOR > REFLEXES> DTR GRADING VERTEBRAL LEVEL Grade 0 ABSENT Grade 1 PRESENT Grade 2 BRISK Grade 3 VERY BRISK Grade 4 CLONUS
- 28. SENSORY EXAMINATION Test from [ABNORMAL] [NORMAL] Test Bilaterally
- 29. Sensory Examination Pain Superficial Deep Temperature Touch Proprioception Two-point discrimination Vibration Pressure
- 30. SPINAL TRACTS
- 31. NEUROLOGICAL EXAMINATION > SENSORY> Pain SUPERFICIAL PAIN Demonstrate the process to the patient Use paperclip / allpin Do not use hypodermic needle Always move: area of impaired sensation normal sensation DEEP PAIN Squeeze muscles of forearm, calf,TA
- 32. NEUROLOGICAL EXAMINATION > SENSORY> Touch Use: Cotton wool/ tip of finger Hypoaetsthesia/ Anesthesia/ Hyperaesthesia
- 33. NEUROLOGICAL EXAMINATION > SENSORY> Proprioception Great toe is tested Demonstrate movements of great toe “upwards” and “downwards” to the patient (whilst they watch) Patient- asked to close eye Examiner – one hand’s- thumb & index finger: held PP firmly from side another hand- thumb & index finger: held DP of great toe & move to a particular direction Pt. asked to identify the direction Test continued till- 6 successive correct responses are given
- 34. NEUROLOGICAL EXAMINATION > SENSORY> Vibration 128 Hz (or 256 Hz ) tuning fork First placed on clavicle – let the pt identify sensation of vibration Pt.eyes closed place @ : [MM] [TT] [ASIS] [DER] [OLEC] [RIBS] Note for degree of vibration felt, promptness of cessation of vibration Compared with clavicle experience
- 35. NEUROLOGICAL EXAMINATION > SENSORY> Two-point discrimination Ability to confirm that a stimulus consists of two blunt points when they are simultaneously applied Initially apartapproximated till patient starts making mistakes Normally: 2mm apart on fingertip Minimum distance:TONGUE Maximum difference: BACK (4cm)
- 36. NEUROLOGICAL EXAMINATION > SENSORY> Temperature Test tubes containing hot and cold water Back of tuning fork/hammer
- 37. AUTONOMIC SYSTEM = Bladder and Bowel Function B & B involved or not If involved. : UMN or LMN
- 38. UMN BLADDER OR LMN BLADDER UMN BLADDER LMN BLADDER LESION ABOVET11 LESION S2 AND DISTAL SPASTIC FLACCID FAILURETO STORE FAILURETO EMPTY LOW CAPACITY LARGE CAPACITY URGE INCONTINENCE OVERFLOW INCONTINENCE “AUTO-MATIC BLADDER” “AUTO-NOMIC BLADDER”
- 39. SACRAL SPARING PERI ANAL SENSATION ANAL CONTRACTION PRESENT GREATTOE FLEXION PRESENT preservation of sacral function might be the only finding to indicate an incomplete cord lesion (which has the potential for recovery) in an apparently complete cord lesion
- 41. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX C5 DELTOID (Axillary N.) SHOULDER ABDUCTION Lateral arm BICEPS (Musculocutane ous N.) ELBOW FLEXION METHOD
- 42. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX C6 ECRL ECRB (Radial nerve) WRIST EXTENSION Lateral forearm Thumb Index finger BRACHIORADIALIS REFLEX
- 43. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX C7 TRICEPS (Radial Nerve) ELBOW EXTENSION Middle finger FCR (Median N) WRIST FLEXION TRICEPS REFLEX
- 44. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX C8 FDS (Median n.) FDP (M + U n.) LUMBRIC. (Ulnar n.) FINGER FLEXION Medial forearm Ring, small finger NONE T1 Dorsal interossei (Ulnar N.) Palmar interossei (Ulnar N.) FINGER ABDUCTION FINGER ADDUCTION Medial arm
- 46. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX T2-T12 INTERCOA STAL MUSCLES Difficult to evaluate individually RECTUS ABDOMINI S This muscle segmentally innervated by T5-T12 BEEVOR’S SIGN
- 47. Beevor’s sign “When a patient sits up or raises the head from a recumbent position, the umbilicus is displaced toward the head.This is the result of paralysis of the inferior portion of the rectus abdominal muscle, so that the upper fibers predominate pulling upwards the umbilicus.” How to perform the test: the patient should be in a supine position. patient is asked either to flex his neck or to sit up from the recumbent position without using the arms (the patients can keep their arms across their chest). Once the umbilicus moves upward, it is a positive Beevor sign. It is negative if the umbilicus remains in its position. Spinal cord lesion betweenT10 andT12 segment facioscapulohumeral muscular dystrophy (diagnostic) “navel moves UP when head moves DOWN”
- 48. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX [T12 L1 L2 L3] (no specific muscle for each root) ILIO- POSAS (T12-L3) QUADRICEPS (Femoral N.) HIP ADDUCTORS (Obturator N.) HIP FLEXION KNEE EXTENSION HIP ADDUCTION NONE
- 49. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX L4 TIBIALIS ANTERIOR (Deep Peroneal N.) Foot inversion Medial side of leg & foot PATELLAR TENDON REFLEX
- 50. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX L5 EHL (DPN.) EDL (DPN.) GREATTOE EXTENSION TOES EXTENSION LATERAL LEG AND LATERAL DORSUM OF FOOT NONE G. MEDIUS (Superior Gluteal N.) HIP ABDUCTION
- 51. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX S1 PERONEUS LONG. & BREVIS (Superficial Peroneal N.) ANKLE EVERSION LATERAL FOOT + PART OF PLANTAR SURFACE OF FOOT + CALF ACHILLES REFLEX G. MAXIMUS (Inferior Gluteal Nerve) HIP EXTENSION
- 52. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX S1 GASTROCN EMIUS- SOLEUS (Tibial N.) PLANTAR FLEXION TOE WALKING
- 53. ROOT MUSCLE SUPLIED ACTION METHOD SENSORY REFLEX [S2 S3 S4] (no specific muscle for each root ; no way of isolated muscle testing) INTRINSIC MUSCLES OF FOOT PRINCIPAL NERVE SUPPLY OF BLADDER SUPERFICIAL ANAL REFLEX
- 54. SUMMARY UPPER LIMB LOWER LIMB
- 55. THANKS !
Editor's Notes
- Points where maximal muscle mass is present (i.e. max girth)
- 3. Ankle clonus o Position the patient’s leg so that the knee & ankle are 90º flexed o Rapidly dorsiflex & partially evert the foot o Keep the foot in this position o Clonus is felt as rhythmical beats on dorsiflexion/plantarflexion (>5 is abnormal)
- The Monosynaptic Stretch Reflex A monosynaptic reflex, such as the knee jerk reflex, is a simple reflex involving only one synapse between the sensory and motor neurone. The pathway starts when the muscle spindle is stretched (caused by the tap stimulus in the knee jerk reflex). The muscle spindles are responsible for detecting the length of the muscles fibres. When a stretch is detected it causes action potentials to be fired by Ia afferent fibres. These then synapse within the spinal cord with α-motoneurones which innervate extrafusal fibres. The antagonistic muscle is inhibited and the agonist muscle contracts i.e. in the knee jerk reflex the quadriceps contract and the hamstrings relax. The sensitivity of the reflex is regulated by gamma motoneurones – these lead to tightening or relaxing of muscle fibres within the muscle spindle. It is thought that this takes place to allow preservation of the stretch reflex when muscles are contracted, although not much is known about it.
- ANKLE CLONUS Support the patient’s leg, with both the knee and ankle resting in 90° flexion. Briskly dorsiflex and partially evert the foot, sustaining the pressure (do not leave the hand after dorsiflexing). Clonus is felt as repeated beats of dorsiflexion/plantar flexion. PATELLAR CLONUS The legs should be extended and relaxed. Examiner grasps the patella between index finger and thumb and executes a sudden, sharp, downward thrust, holding downward pressure at the end of the movement. Clonus is felt as repeated upward and downward movement of the patella. Pseduoclonus or False clonus Pseduoclonus is observed in psychogenic disorders
- Locks fingers and pull against one another
- Demonstrate and assure him that the needle wont hurt. Patient will appreciate the change immediately. DEEP PAIN Increased: SACD, Infective polyneuritis Decreased: Tabes Dorsalis, Syringomyelia
- not to hold the toe or finger on its top and bottom, or else the patient would detect its position from the differential pressure above and below the digit
- Important and clinically relevant indicator of autonomic status---bowel bladder function
- 1.Perinanal sensation 2.gloved finger inserted per rectum and look for voluntary anal contraction
- C1-C4 Difficult to test C4: Major innervation of diaphragm via Phrenic nerve (C3,4,5) Significant breathing problems ; may require mechanical ventilation