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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