IB CSL ORTHO
CLINICAL EXAMINATION OF SPINE
Dr Chong Chee Seang
Ortho
Fri 27-09-02
STANDARD CLINICAL EXAMINATION
Hx
Pain
- Mechanical - assoc. with instability (eg. Degenerative spine disease, trauma, spondylitis)
- Rest - tumour, infection (disturb sleep at night)
- Neuro: numbness, weakness of limb
Inspection
- Exposure Pt adequately
- Gait - swing upper limbs?
Palpation
ROM testing and Specific Test
Neurovascular Exam
- SC in spine
- Spinal stenosis: can confuse neural claudication with vascular claudication
Diagnostic Imaging Studies
INSPECTION
Gait
- Antalgic - painful, stance phase short on painful size
- Tredenlenberg - caused by weak hip abductors
- Short limb gait - pelvis sags on shorter side
- Spastic gait - small steps, clumsy
Swing of arm
- Cervical problem - weakness, spasticity of arm
Overall condition
Undress to his/ her underwear - watch the Pt undress
- Most important
- Eg. Cervical myelopathy (neuro-deficit) - may not be able to unbutton clothes
POSTERIOR INSPECTION
- Deviation from vertical in coronal plane
® scoliosis
Shoulder obliquity ® same level
Pelvic obliquity® same level, pelvis tilts with short limb
Waist line ® asymmetry in scoliosis
Body hair ® patch of hair at lumbar region - myelomeningocele, spinal bifida
Muscle contour ® injury, spasm, unilateral m spasm usually association with postural scoliosis ( not structural scoliosis)
Skin changes ® neurofibromatosis (cafe au lait spots)
SLIDE - Scoliosis
- Prominent scapulae
- Hypokyphosis at thoracic region
SLIDE - Scoliosis
- UMN sign of LL (spina bifida)
- Neuromuscular scoliosis
SLIDE - Fwd bending test (scoliosis)
- See hump
- Thoracic site - rib deformity
- Lumbar - rotation of vertebral body
SLIDE - spina bifida
SLIDE - cafe of lait spots
- Hyperpigmented patches in right subscapular region + cafe au lait spots
- Scoliosis
- Neurofibromatosis (usually see spots first then search for scoliosis)
LATERAL INSPECTION
- Saggital profile
- Kyphosis of thoracic spine - loss, exacerbation
- Sherman's disease - smooth kyphosis
- TB - angular kyphosis (destruction of disc, endplate, body)
- Lordosis of lumbar spine - loss
- Eg. Acute PID - m spasm - loss of lordosis
- Lumbosacral junction - step present?
- Spondylolisthesis - one vertebra slips fwd in top of another - feel/ see step because spinous process moves forward (usually at L4/5, L5/S1)
POSTURE & ALIGNMENT
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
- Importance of balance
SLIDE - Ankylosing spondylitis
- Exaggerated thoracic kyphosis
- Flat back (loss of lumbar lordosis)
- Hyperextended neck
ANTERIOR INSPECTION
- Head position - tilt? ®
Eg. Torticollis (SCM fibroma), congenital C1/2 subluxation
- Axial of vision ®
Eg. AS cannot see above horizontal line (can only see down because they are so stiff)
- Facial asymmetry ®
Eg. C1/2 subluxation, torticollis (if untreated)
- Rib cage deformity ®
Eg. Kyphosis, scoliosis, AS, TB (progressive chest deformity due to angular kyphosis)
- Transverse abdominal fold ®
(1) Eg. Serious spondylolisthesis - whole vertebra drops anteriorly (2) Eg. TB - if angular kyphosis serious enough (3) Sometimes deformity so serious that ribcage rests on iliac crest
PALPATION
Spinous processes - know landmarks
Paravertebral muscle
Point tenderness - eg. tumour
Diffuse tenderness - eg. PID (spasm of intervertebral muscles)
CERVICAL SPINE
- Spinous processes
- Facets
- Anterior body
- General exam of neck - eg. LN
THORACIC & LUMBAR SPINE
- Prone
- Spinous processes
- Facets
- Levels
- Iliac crest - L4
- C7
- 12th rib - last floating rib felt
- Widespread superficial tenderness
- Non-anatomic tenderness
ROM
Distance between fingers and floor (should be < 10 cm)
Flexion + extension of lumbar spine
- Neutral position - T 30 cm, L 10 cm
- Flexion - T 32 cm, L 17 cm
- Extension - T 29 cm, L 7 cm
CERVICAL SPINE
- Flex - chin to chest
- Extension - Nose and forehead horizontal
- Lateral flexion - ear to shoulder
- Rotation - chin just before shoulder
THORACIC & LUMBAR SPINE
Thoracic
- Rotation 30 degrees
- Rib cage movement (in AS): exhale totally (measure circumference), then inhale (N = 8-10 cm; severe AS = no movt)
Lumbar
- Fwd flexion
- Toe touch
- Hip or spine - measure excursion of spine
- Rhythm
LUMBAR SPINE
- Extension
- Side flexion - touch thigh and flex, usually reach knee
- Rotation
NERVE ROOT TENSION SIGNS
Straight leg raising test (SLR test)
Pt lie flat
Put hand on heel of Pt
Slowly raise leg
+ve test =Pt has shooting pain from back to ankle
-ve =Pt has pain at back but not shooting pain down leg
Report: SLR test +ve at ___ angle
Femoral stretch test
- Testing higher nerve root (L2-4)
- Lie Pt lateral
- Hyperextend hip joint
- +ve = pain distribution along femoral nerve
OTHER CONSIDERATION
Pelvic obliquity - limb length discrepancy
Eg. Postural scoliosis - ask Pt to sit on side of bed (eliminates leg length discrepancy)
If obliquity disappears - postural scoliosis
If obliquity remains - structural scoliosis
Hip problem - Tredelenburg test
QUICK TEST
Gait - pelvic sag? Stride length? Walk in straight line?
Remove clothing
Inspection from posterior - shoulders, pelvis, asymmetrical skin fold, hair patches, abn discoloration
Inspect from side - normal thoracic kyphosis and lumbar lordosis
Palpation - neck - start at sternoclavicular, acromioclavicular jt, spinal processes (ask for pain), paravertebral m, facet joint, can punch with bottom of palm to elicit pain
ROM - look L + R, ear to shoulder
Lumbar spine - L4 at iliac crest - measure distance in neutral, flexed, extended positions
Thoracic spine - Pt sitting - Pt clasp hands in front (hand to elbow), rotate L + R
Straight leg raise - explain to Pt what you're doing ("I'm going to raise your leg, if you feel discomfort or pain, let me know) - start on normal side - look at Pt's face - measure angle at which pain occurs [Lasegue test - lower leg, no more pain, dorsiflex ankle to stress nerve root] [Bow-string test: flex knee to 90 degrees - raise leg, pressure part that is bow-straight]
Trendelenburg test
- Test from back: put fingers at iliac crest (squat down), lift R leg fwd knee flexed. If problem with hip adductors, will sag down (look at pelvic level)
- Test from front: Pt palms on your up-facing hands, lift leg, will feel increased pressure on palm