Examination Of The Spine Flashcards
1
Intro
2
Inspect them from the front, the side and behind. Need good exposure so should be dressed in bra and pants
-Inspect their skin, looking for café-au-lait spots, which may suggest neurofibromatosis, a sacral dimple, naevus or hairy patch suggestive of spina bifida occulta, or scarring suggestive of a previous thoracotomy or spinal surgery.
- Inspect the cervical spine for deformity (e.g. cervical spondylosis, acute torticollis). An abnormal head posture may be due to disease in the cervical spine or neck, but you should also consider other causes e.g. extraocular muscle palsy. Look for asymmetry of the clavicles, scapulae and shoulders.
-Inspect the thoracolumbar spine for kyphosis or scoliosis
(Do gait here)
3
Palpation
Palpate for tenderness over the spine and soft tissues
-Palpate the cervical spine and neck posteriorly in the midline, laterally, and anteriorly,
-Examine the supraclavicular fossae for any masses (e.g. cervical rib, lymph glands, tumours) and the paraspinal muscles for tenderness.
-Palpate the thoracolumbar spine and sacrum for tenderness. Tenderness between the spines of the lumbar vertebrae, at the lumbosacral junction and over the lumbar muscles may occur with a prolapsed intervertebral disc and with mechanical back pain.
-A palpable step at the lumbosacral junction may indicate spondylolisthesis.
-Palpate for tenderness over the sacroiliac joints (e.g. ankylosing spondylitis).
4
Assess range of motion
Assess the active ROM of the cervical spine
Flexion: normal range 80°, chin able to touch sternoclavicular joint.
o Extension: normal range 50° (note: flexion and extension primarily involve the atlanto-axial and atlanto-occipital joints).
o Lateral flexion: normal range 45° from midline. Restriction of lateral flexion is common in cervical spondylosis.
o Lateral rotation: normal range 80° to both sides. Rotation is restricted and painful in cervical spondylosis.
4… (please note)
If there is restriction of any active cervical spine movement then cautiously check passive range of motion to identify if there is any further increase in the range of motion. Ask the patient to perform the active movement and then cautiously, with one hand on the neck to feel for crepitus and the other hand on the top of the head to create the movement, slowly and gently attempt to passively move the cervical spine beyond the active range.
5
Assess the movement in the thoracic and lumbar spine
Flexion is due to a combination of thoracic, lumbar and hip movements. The composite movement may be recorded as the distance between the patient’s fingers and the ground (normally < 7cm) or the lowest level that the person can reach (e.g. mid-tibia).
5 pt 2
A modified Schober’s test should be used to provide a quantitative evaluation of flexion of the lumbar spine. Mark a 15cm length of the lumbar spine with the patient in the erect position), measuring 10cm above and 5cm below the posterior superior iliac spines (Dimples of Venus). Instruct the patient to flex his or her spine maximally. Re-measure the distance between the marks. Normal flexion increases the distance by at least 5 cm.
6
Extension. Ask the patient to arch their back (normal range=thoracic 25°,lumbar 35°). Pain and restricted extension are particularly common in prolapsed intervertebral disc and spondylolysis.
7
Lateral flexion. Ask the patient to stand erect with hands at their sides and feet 30cm apart. Measure the distance from the finger tips to the floor. Ask the patient to flex maximally to the side and re-measure the distance from the finger tips to floor. The difference between the two measurements is recorded as the amount of lateral flexion (normal >10cm). The contributions of the thoracic and lumbar spine to lateral flexion are usually equal.
8
Rotation. The patient should be seated, asked to fold their arms across their chest then asked and to twist round to each side. The normal range of rotation is 40° and is almost entirely thoracic. The lumbar contribution is <5°.
9
Ask the patient to bend forward and lightly percuss the spine from the root of the neck to the sacrum. Significant percussion tenderness is a feature of infection, fractures and neoplasia.
10
Assess the patient’s gait
(I’d probs do this at start)
11
Completion
Perform a full neurological examination of the patients upper and lower limbs, looking for fasciculation, wasting, and abnormalities in tone, power, reflexes and sensation. Remember that cervical spinal cord compression may lead to bladder and bowel disturbance, lower limb neurological dysfunction and abnormal gait.
In a patient presenting with lower back pain, perform an abdominal examination to identify any masses, and consider a rectal examination (omit in the OSCE) to check for loss of anal tone and perianal sensation (cauda equina syndrome).
Examine the peripheral pulses as vascular claudication in the upper and lower limbs may mimic the symptoms of radiculopathy or canal stenosis.
In patients presenting with neck pain, you should also examine the shoulder joints. In patients presenting with lower back pain you should examine the hip joints. Osteoarthritis of the hip may present with predominantly back and buttock pain as well as with pain in the groin.
Special tests
The following special tests should be performed, as an addition to the basic examination above, when indicated by the clinical history:
Suspected prolapsed intervertebral disc
Straight leg raise. Ask the patient to lie flat on the couch. Passively flex their thigh with their leg extended. If the patient complains of back or leg pain the test is positive (hamstring tightness is not relevant).
Paraesthesiae or pain in a nerve root distribution indicates nerve root irritation. Back pain suggests, but is not indicative of, a central disc prolapse, and leg pain suggests a lateral protrusion.
Lower the leg gradually until the pain disappears then dorsiflex the foot. This increases tension on the nerve roots, aggravating any pain or paraesthesiae (Lasegue’s sign).
