EXAMINATION OF SPINE

Presenter - Dr. Guru prasad (DNB ORTHO )

Introduction

Vertebral Body

Pedicle

Lamina Superior Articular Process

SpinousProcess

Transverse Process

Vertebral Foramen

Vertebral Structures

Superior Articular Process

Inferior Articular Process

Zygapophyseal Joint

(Facet Joint)

Pars

Vertebral Structures

Vertebral Structures

• Pedicle notchesSlight Notch

Deep Notch

Intervertebral Foramen

• INTERVERTEBRAL FORAMEN through which the spinal nerve roots

leave the spinal cord

• Anterior ArchComprised of:– Vertebral body – Anterior 1/3 of the pedicles

• Posterior ArchComprised of:– Posterior 2/3 of the pedicles– Lamina– Processes

Vertebral Arches

Arteries of the Thoracic and Lumbosacral RegionsVertebral artery Aortic arch

Ascending aorta

Descending aorta

Thoracic segmental arteries

Abdominal aorta

Bifurcation of the aorta Lumbar

segmental arteriesExternal iliac

artery (left & right) Internal iliac

artery (left & right)Femoral artery

(left & right)

Batson’s PlexusThe AZYGOS SYSTEM is a large

network of veins draining blood from the intestines and other abdominal organs back to the heart. The segmental veins drain into the azygos vein located on the right side of the abdomen, or into the hemiazygos vein located on the left side.

The azygos system also communicates with a valveless venous network known as BATSON’S PLEXUS. When the vena cava is partially or totally occluded, Batson’s plexus provides an alternate route for blood return to the heart.

The vessels of Batson’s plexus may be referred to as epidural veins

Batson’s plexus

• C7 – Prom. Spinous Process

T3- Level with Medial Scapular Spine

T7 – Inferior angle of scapula

L2 – Lowest Rib

L4 – Iliac Crest

Spinal Nerve StructuresSpinal Cord• Contained in epidural space• Network of sensory and motor

nerves• Firm, cord-like structure

Foramen magnum

• Extends from foramen magnum to L1

• Terminates at the conus medularis

• The cauda equina begins below L1

• Filum terminale extends from conus medularis to the coccyx

Conus medularis

Cauda equina

Spinal NervesSpinal cord

Epidural space

Dura mater and Arachnoid layers

Subarachnoid space

Dorsal root

Ventral root

Dorsal root ganglion

Peripheral nerve

Meninges

Dura mater

Subdural space

Arachnoid layer

Subarachnoid space: filled with CSF

Pia mater

Within the spinal canal, the spinal cord is surrounded by the EPIDURAL SPACE, filled with fatty tissue, veins, and arteries. The fatty tissue acts as a shock absorber.

The spinal cord is covered by MENINGES which has three layers.

Functions of spine

• Spinal cord encasement• Weight transmission• Posture• Vital organs back support• Muscles attachment

Common conditions affecting the spine

Clinical examination of spine

History

Age Disorders

Child spina bifida , Potts disease , congenial scoliosis

Adolescent Idiopathic scoliosis,schurmann’s disease , mechanical back pain ,infections

Young adults PIVD , fracures ,ankylosing spondylosis ,tuberculosis

Middle age Spondylosis, spondylolysthesis, tumors , PIVD

Elderly Osteoporosis ,metastasis ,spondylosis

sex disorder

Male ankylosing spondylitis ,prolapse intervertebral disc , osteoarthritis

Female psychogenic backache,osteomalacia ligamentous strain

• 4.pain-A)Site-cervical region ,dorsal region, in the lumbodorsal region or lumbar region , in the

lumbosacral region or in the sacral region.B)Mode of onset-whether the pain started immediately after trauma or lifting weight or during

strenous exercies as seen in prolapsed intervertebral discC)Nature of pain- Stabbing –pivd Continous and throbbing type in osteomyelitis Intermittent pain –spondylolisthesis Dull ache in pott’s diseaseD)RadiationE)aggravating factorsF)relieving factors-restG)Positional varianceH)Rest pain

• Deformity-localized/diffuse ,onset progression• Swelling –site ,onset,1st noticed, duration, progression• stiffness of the back• Weakness – unilateral/bilateral motor /sensory sudden /insidious duration progression bowel/bladder involvement –early/late• Restriction of ROM• Abnormality in walking• Disability

Ask for…

Past history

Personal history

Family history

General examination

Inspection

Standing(a) Look from the side

i. normal spine> cervical lordosis> thoracic kyphosis> lumbar lordosis

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

Gibbus (angular kyphosis)> fracture> tuberculosis of the spine> congenital abnormality

. 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 pregnant women)- spondylolisthesis- secondary to increased thoracic curvature or to flexion deformity of the hips

Look from behindi. 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 tiltiv. Pelvic tilt

v. Skin changes over the spine- hair tuft (spina bifida)- sinus - colour changes or pigmentation (neurofibroma)- scar

vi. Swellingvii. Prominent crease of the trunkviii. Wasting of paraspinal muscles, glutei,

hamstrings and calf muscles

Palpation

3.SWELLING-Spina bifida-meningocele in the sacral or occipital regionCongenital sacrococcygeal teratoma in sacrococygeal region

MEASUREMENTS

1. Linear measurements a. From external occipital protrubence to tip of coccyx b. Iliocostal distance ( tip off last rib to iliac cest) c. Segmental measurement d. Acromiooccipital distance e. Schober`s test f. Otto test2. Chest expansion3. Limb length discrepancy

Cervical spine

Consist of 7 vertebra

8 nerves

Give two plexuses

Cervical plexus ( C1-C5) brachial plexus ( C5-T1)Phernic ( C3,C4,C5) mucocutanous n (C5-C7)

Lesser occipital (C2) axillary n (C5-C6)

Supraclaviclular ( C3,C4) median n (C5-T1) radial N (C5-T1)

ulnar n (C8-T1)

Cervical spine

History * acute traumaHistory of Falling down , vehicle accident .Any patient unconious form after heard injury you should assumed it as cervical spine injury.ABC, WAIT FOR help , x –ray frontal & lateral

Cervical spine

History

* PAIN :- analysis of pain

Acute ,sub acute ,chronic

Onset ,duration , character , severity ,radiation ,reliving ,aggravating factor

At end of day /at night , other joint affected

*Weakness in upper limb

*Paraesthesia

Cervical spine

History

Pain and difficulty turning the head and neck, examples are: → Disease of atlanto-occipital joints produces pain radiating to the occiput. → Spondylosis of the middle and lower cervical spines causes pain radiating to the upper border of trapezius, interscapular region, and the arms. → Irritation of the C6 & C7 nerve roots can give rise to referred pain in the interscapular region, radial fingers, and thumb. → Irritation of C8 can cause pain on the ulnar side of forearm, ring, and little fingers.

Cervical spine

Physical examination:

Look Observe the posture of the head and neck and note any abnormality and deformity, e.g. loss of lordosis. Feel → The midline spinous processes → The paraspinal soft tissues → The supraclavicular fossae – for cervical ribs or enlarged lymph nodes → The anterior neck structures including the thyroid

CERVICAL SPINE

Forward flexion Normal : 75 to 90 degrees

Extension Normal : 45 degrees

Right lateral flexion Normal : 45 to 60 degrees

Left lateral flexion Normal : 45 to 60 degrees

Rotation to right Normal : 75 degrees

Rotation to left Normal : 75 degrees

Special tests Cervical spine :

Compression testDistraction testValsalva testSwallowing testAdson test

COMPRESSION TEST

Press down upon the top of pt’s head

If there is increase pain in either cervical spine or upper extremity, note its exact distribution. So, we can locate the neurological level

A narrowing of neural foramen, pressure on the facet joints or muscle spasm can cause increase pain upon compression

DISTRACTION TEST

Place the open palm of one hand under the pt’s chin, and the other hand is upon occiput

Then, gradually lift (distract) the head to remove its weight from the neck

To demonstrate the effect that neck traction might have help in relieving the pain by decreasing pressure on the joint capsules around the facet joints.

VALSALVA TEST

Ask pt to hold his breath and bear down as if he were moving his bowels

Then, ask whether he feels any increase in pain and describe the location

This test increase intratechal pressure

If a space occupying lesion, such as a herniated disc or a tumor present in cervical canal, pt may develop pain in cervical spine secondary to increase pressure

The pain also may radiate to the dermatome distribution of cervical spine pathology

SWALLOWING TEST

Difficulty or pain upon swallowing can sometimes caused by cervical spine pathology such as :Bony protuberanceBony osteophytesSoft tissue swelling due to

hematomas, infection or tumor in ant portion of cervical spine

NAFFZIGER’S TEST

manual compression of the jugular veins bilaterally. An increase or aggravation of pain or sensory disturbance over the distribution of the involved nerve root confirms the presence of an extruded intervertebral disk or other mass.

LHERMITTE’S SIGN

This sign detects protrusion of cervical intervertebral disc or an extradural spinal tumour irritating the spinal duramater.

The patient sits on an examining table,now the head of the patient is bent down passively(flexion of cervical spine ) and simultaneously the lower limbs are lifted(flexing the hip joints) keeping the knees straight. This will causes sharp pain radiating down the spine and to both the extremities.

ADSON TEST

Pull the arm downwards Palpate the radial pulse Turn the pt’s head to the same side and extend the neck Abduct, extend, and laterally rotate the shoulder. From this position, have the patient take a deep breath and hold Feel the radial pulse Fading of the radial pulse indicates positive thoracic outlet obstruction

Thoracic spine( T1-T12)

History

→ Commonly, localized spinal pain, examples are: Ankylosing spondylitis produces pain in the thoracolumbar region Acute thoracic spinal pain may be due to vertebral prolapse due to

malignancy, or infection; especially if there was systemic upset or fever is present

→ Less commonly, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control

Thoracic spinePhysical examination:

Look With the patient standing, inspect posture from behind, the side and the front, noting any deformity, e.g. rib hump or abnormal curvature. Feel → The midline spinous processes → The paraspinal soft tissues → If there is increased prominence of one or more spinous processes implying anterior wedge-shaped collapse of the vertebral body – often related to osteoporosis. Move Ask the patient to sit with arms crossed, and to twist round and look at you

Lumbar spineLUMBAR NERVES( L1-L5)SACRAL NERVES ( S1-S4)

LUMBAR PELUXES ( L1-L4)illioingunal (L1) , iliohypogastric (L1) ,

genitofemoral (L1-L2), Femoral (L2-L4)Obuturator (L2-L4)SACRA L PELUXESSCIATIC NERVE (L4 –S3)1- Common peroneal2- Tibia

Lumbar spine

History

→ Low back pain is an extremely common complaint → Sacroilitis produces pain that is referred down both legs to knees → Consider abdominal and retroperitoneal pathology, e.g. abdominal aortic aneurysm, pancreatitis, peptic ulcer, renal pathologies.

Lumbar spineRed flag features for acute low back pain:

→ In History: Age < 20 yrs or > 55 years Recent significant trauma (fracture) Pain:

Thoracic (dissecting aneurysm)Non-mechanical (infection/

tumor/pathological fracture)Fever ( infection)Difficult micturitionFecal incontinenceMotor weaknessSaddle anesthesiaSexual dysfunctionGait change ( cauda equina

syndrome)Bilateral sciatica

Lumbar spineRed flag features for acute low back pain:

→ In Past medical History: Cancer ( metastasis.) Previous steroid use (osteoporotic

collapse)→ In Systemic review: Weight loss/malaise without obvious cause

(e.g. cancer)

Lumbar spine

Physical examination:

Look Examine the patient standing. Look for obvious abnormality such as decreased/increased lordosis, obvious scoliosis soft tissue abnormalities such as a hairy patch or lipoma that overlie spina bifida. Feel Palpate the spinous processes and the paraspinal tissues. The L4/L5 interspinous space is palpable at the level of iliac crests.

Thoracic and lumbar spine

Forward flexion (Schober’s test)Normal : 90 degrees

ExtensionNormal : 30 degrees

Lateral flexion to left and rightNormal : 30 to 45 degrees

Rotation to left and rightNormal : 45 degrees

1)flexion- adult:- flexion is tested by asking him to lean forward

keeping the knees straight .The clinician places his hands over the spine to note the movements of the spinous processes.It must be noted how much of the movements occurs at the spine and how much the hip flex.

children-:-ask him to pick up on object from the floor.when the spine is rigid the child will stoop bending his knees and hips keeping the spine straight.while raising the body he puts his hands successively on the legs ,knees and thighs as if he is climbing up his own legs.

2)extension:- Adult- patient may be asked to lean backwards.

Note the range of extension movement. This movement mainly occurs in the lumbar region.

• Children- in case of children the patient is laid on his face.The clinician lifts up his legs in an attempt to bend the lumbar spine whilst the other hand fixes the dorsal spine.If the lumbar spine is affected it cannot be bent but will be lifted as one piece

3)lateral flexion:- adults are asked to bend sideways while standing .

In children these movements are demonstrated by lifting up the legs as in testing extension and then by carrying the legs first to one side and then to the other to bend the spine sideways.

The other hand of the clinician is placed on the thoracic spine to detect the movements of the spine.

Schober’s test

Schober’s test for forward flexion1- Erect position. 2- Select 2 bony points (POSTERIOR SUPERIOR ILLIAC SPINE)3-Maximum flexion on lumbar with fix knee.4-the two points should separate by at least a further 5cm.

4) Rotations:- the patient is always asked to sit down so as to fix his pelvis.He is then instructed to rotate the trunk to the right and to the left.

E. MEASUREMENT- the lengths of the lower limb must be measured to exclude shortening of any limb as the cause of scoliosis.

Special tests Thoracic and lumbar spine

Straight leg raising testLASSEGUE’S SIGNCross SLRTReverse SLRTFemoral stretch testBowstring test

STRAIGHT LEG RAISING TEST

STRAIGHT LEG RAISING TEST

The patient lies supine on the examining table. First exclude that there is no compensatory lordosis by

keep a hand beneath the lumbar spine. The patient is now asked to raise one lower limb keeping

knee straight and continue to raise the leg till he experiences pain as evidenced by watching his face.

If the pain is evoked under 40 degrees it suggests impingement of the protruding intervertebral disc on a nerve root.

If the pain is evoked at an angle above 40 degree It indicates tension on nerve root that is abnormally

sensitive from a cause not necessarily an intervertebral disc protrusion.

LASSEGUE’S SIGN

At this angle when the patient experiences first twinge of pain,the angle is pasively dorsiflexed.This causes aggravation of the pain due to additional traction to the sciatic nerve (LASSEGUE’S SIGN).

This is imp to differentiate sciatica from diseases of sacro-iliac joint.

In sacro iliac joint diseases the SLRT is positive but there will be no aggravation of pain during passive dorsiflexion of the ankle

Cross SLRT

Reverse SLRT

Bowstring test

FEMORAL NERVE STRETCH TEST

A patient with lumbar disc prolapse may complain of pain in front of the thigh,this indicates that probably the protruding disc is l2-l3 which is irritating the femoral nerve.

The patient is asked to lie on his abdomen and flex the knee of the affected side, if this causes pain then its confirmatory that L2-L3 lumbar disc is protruded to cause stretching of the femoral nerve.

SACRO –ILIAC JOINT

Inspection –the patient is stripped and examined in standing ,sitting and recumbent positions.

The position of the sacro iliac joint is determined by presence of dimple situated just medial to the posterior superior iliac spine.

In standing postion the patient is asked to point out the site of pain and direction in which it radiates.

In recumbent position it should be noted whether the hip and knee joints are slightly flexed or not

PALPATION

Tenderness is elicited by placing the thumb over the dimple and exerting pressure while the patient is asked to bend forward.

It may also be elicited by compressing the two iliac crests together.

SPECIAL TESTS

GENSLEN’S TEST- The hip and knee joints

of the affected side are flexed to fix the pelvis and the hip joint of the unaffected side is hyperextended over the edge of the examining table.

This may exert a rotational strain on the sacro iliac joint and will cause sharp pain.

GILLIES TEST

• The patient lies prone on the bed. The pelvis of the patient is kept steadied by clinician’s hand on the normal sacro iliac joint. The thigh of the affected side is hyperextended passively with the other hand of the clinician. A sharp pain is felt by the patient when the sacro iliac joint is diseased

FABER Test• The patient's tested leg is placed in a "figure-4" position• knee is flexed and the ankle is placed on the opposite knee• The hip is placed in Flexion, ABduction, and External Rotation (which is where the

name FABER comes from)• posteriorly-directed force against the medial knee of the bent leg towards the

table top• positive test occurs when groin pain or buttock pain is produced• sacroiliac joint dysfunction

Compression distraction test

• Examiner crosses arms and places them at the medial aspects of the patients ASIS's

• A gapping pressure is applied in an outward direction bilaterally and simultaneously

• The examiner then uncrosses his/her arms and places his/her hands on the iliac crests to apply an inward/downward force

• NEUROLOGICAL EXAMINATION

• Higher mental function• Cranial nerves• Motor function• Sensory function• Reflexes • Visceral functions• Involuntary movements• Gait

Motor system a. Bulk of muscle ( wasting or hypertrophy) b. Tone of muscle i. Hypertonia 1. Spasticity 2. Rigidity ii. hypotonia c. Power of muscle d. Reflexes

Nerve root Test

C5 Elbow flexion

C6 Wrist extension

C7 Wrist flexion

C8 Finger flexion

T1 Finger abduction

• Upper limb • C5 - lateral forearm • C6 - lateral forearm • - thumb and index finger• C7 - middle finger• C8 - ring and little fingers• - medial forearm• T1 - medial elbow• - distal half of the medial arm • T2 - proximal half of medial arm

ReflexesBiceps (C5-6)BrachioradialisTriceps (C7-8)

• Reflexes– Knee jerk (L3-4)– Ankle jerk (S1-2)– Babinski’s reflex– Clonus

L1,2 Hip flexion

L3,4 Knee extension

L4 Dorsiflexion

L5 Great toe extension

S1,2 Plantarflexion

Lower limbL1 – groinL2 – anterior thighL3 – anterior kneeL4 – medial aspect of

legL5 – lateral aspect of

leg - dorsal aspect of

footS1 – lateral aspect of footS2 – posterior aspect leg

and thighS3,S4,S5 – perianal region

• Sensory system• a. Temperature• i. Hot• ii. cold• b. Touch• i. Deep• ii. Crude• iii. Light• c. Posterior column sensations• i. Two point discrimination• ii. Vibration sense ( 128 Hz)• iii. Position sense• iv. stereognosis

• Co ordination mechanism• a. Straight line walking• b. Finger to nose & finger test• c. Heel to knee test• d. Romberg sign• e. Pastpointing• f. Dysdidokinesia

Gait