History taking and examination of the spine

Question 1

Describe the normal alignment of the spine

Answer 1

1) Cervical lordosis

2) Dorsal/thoracic kyphosis

3) Lumbar lordosis

4) Sacral kyphosis

Question 2

What are the red flags when examining the spine?

Answer 2

Indicated early on for:

• Current medical history:
  1) Significant trauma
  2) Recent interventions
  3) Pain that is not relieved or worsens when lying down
  4) Pain that worsens at night
  5) Progressive neurological deficit
• Past medical history:
  1) Cancer
  2) Recent rapid weight loss
  3) Immunosuppression or systemic steroids
  4) IV Drug use, recent bacterial infection, chills or fever
  5) First incident of back pain in older patients

The patient should be offered an urgent appointment if:
1) fever that lasts for >48 hours
2) Saddle anesthesia (rectum, perineum, and the inner thigh)
3) New leg weakness
4) Loss of bladder or bowel control (retention/incontinence)
5) Progressive neurologic deficit

Question 3

What is the way of inspecting the spine?

Answer 3

1) LOOK

2) FEEL

3) MOVE

4) SPECIAL TESTS

Question 4

What are the things to look for when examining the spine?

Answer 4

1) Posture, deformity (straight, torticollis, ankylosing spondylitis “منزل راسه وظهره”)

2) Skin

3) Spondylitis

4) Swellings (sternocleidomastoid lump)

5) Muscle wasting

6) Level of the scapula (can differ in scoliosis)

Question 5

What are the things to feel when examining the spine?

Answer 5

• By palpating you are looking for tenderness (bony or soft tissue), Increased interspinous distance, fluid collection

1) Bony prominences

2) Spinous processes

3) Body attitude
- Torticollis (neck)
- Postural scoliosis (thoracolumbar)
- Antalgic gait (severe LBP)

4) Soft tissues

5) Swelling

6) Muscle spasm

Question 6

What are the movements done when examining the spine?

Answer 6

1) Flexion/Extension

2) Chin up & down

3) Lateral flexion (bending towards the right and left)

4) Rotation (right and left)

• If the movements were restricted, it is a clue that the cervical spine is concerned which could be due to a muscle spasm or entrapment of nerve roots

Question 7

What are the special tests done for the spine?

Answer 7

1) Spurling test

2) Straight leg raising test

Question 8

Describe the neurological examination of the spine

Answer 8

1) Examination of the upper limb
- Shoulder, elbow, wrist and hand

2) Examination of the lumbar spine

Gait:
- It is normal or not (as in old people cervical disk diseases can cause myelopathy by pressure on the spinal cord)

It should also include:
1) Sensory
2) Motor (power)
3) Deep tendon reflexes (Biceps, triceps, and brachioradialis tendon reflexes for the UL)

Question 8

Describe the spurling test

Answer 8

Provocative test (the examiner tries to track the nerves concerned with the pain), by aiming to reproduce the symptoms

You simply apply downward pressure to the patient’s head while the patient’s neck is extended and rotated towards the involved side, this movement will narrow the intervertebral foramina on the affected side and reproduce the radiating pain if there is any

Question 9

What is meant by cervical spondylosis?

Answer 9

• It is a degenerative disease, as the disc acts as a shock absorber that maintains the stability of the cervical vertebrae, overtime the disc loses its water content and becomes dehydrated, turning thick and non-functioning and transmitting the load to the sides of the joint, it will produce
• Neck pain
• Limited neck movement
• Paresthesia
• Pain radiates done the UL (Radiculopathy)

Question 9

What are the positions that the patient is examined in when examining the lumbar spine?

Answer 9

1) While standing

• Look from the front, side, and behind
• Palpate the paravertebral muscles, spinous process, and interspinous spaces (you can feel it sometimes)

2) While lying supine

3) While lying prone

Question 10

Describe the straight leg-raising test

Answer 10

• Provocative test that stretches the sciatic nerve
• Basically, you dorsiflex the foot while stabilizing the knee joint you raise the leg
• Normal people can raise their leg to an angle of 60-80 degrees, some people who have tight hamstrings may not stretch it as much
• Someone who has a nerve root compression will not raise it and may only reach 20-30 degrees before complaining of pain

Question 10

What are the movements done to examine the lumbar spinous process?

Answer 10

1) Flexion

2) Extension

3) Lumbar spine rotation

Question 10

Describe the neurological examination of the spine

Answer 10

• It should include sensory, motor, and deep tendon reflexes (Knee and ankle)
• You will see the jerking of the leg and contraction of the quadriceps

Question 11

What is the special test for the lumbar spine?

Answer 11

Straight leg raising

Question 12

What are the symptoms of a prolapsed intervertebral disk?

Answer 12

• It can start from the twenties

1) Lower back pain, THAT RADIATES DOWN THE POSTERIOR HIP, THIGH, LEG, ETC

2) Loss of lumbar lordosis

3) Pain increases when sneezing or coughing

4) Might be associated with burning, numbness (paraesthesia)

Question 13

What is a prolapsed disk?

Answer 13

During disc herniation (nucleus pulposus goes out), there will be a breach in the annulus fibrosus so the nucleus pulposus leaks out due to the pressure coming from the body causing pressure on the nerve roots. Due to the space being tight, even a small amount of this leakage will cause symptoms as this nerve is VERY sensitive
Most commonly affected is the sciatic nerve (nerve root: L4, L5, S1, S2, and S3)

• In the X-ray ou can see it building towards the spinal cord

Question 14

What are the signs of a prolapsed disk?

Answer 14

1) There might be tender spinous processes L4-5 or L5-S1

• L5 Comes from the posterior thigh, posterior hip, outer part of the leg, and the dorsum of the foot (while S1 is the SOLE OF THE FOOT)

2) Decreased ROM of the LS spine

3) SLRT (Lasegue) +ve
Crossed SLRT +ve !!!

4) Sensory or motor deficit in the territory of the involved nerve root

5) Diminished/loss of deep tendon reflex

• If the Bowel and bladder control is impaired 🡪 surgery is needed

Question 15

What is meant by acquired spinal stenosis?

Answer 15

• Stenosis means narrowing (where the canal that contains nerve roots is compressed), due to ligamentum flavum which is a ligament enveloping the canal, it gets calcified and becomes thick, and joints become thick. Sometimes we can see that a disc has prolapsed
• The patient will complain of pain that radiates and increases to both LL, it is a progressive disease that might lead the patient to be unable to walk “claudication” (patient unable to walk due to the pain)
• Commonly found in elderly, hence why they bend their back to relieve some of this pain (why? Nerve roots are not static so when we flex it causes the roots to go up from that narrow area relieving the pressure; diameter of the canal becomes higher so stenosis will be less)

Question 16

What are the signs and symptoms of acquired spinal stenosis?

Answer 16

1) Numbness and tingling of the leg or foot

2) Loss of sensation in the foot

3) Leg cramping and weakness

4) Pain worsens with standing

5) Loss of sexual ability

6) Bowel and bladder dysfunction in severe cases

Question 17

What is meant by cauda equina syndrome?

Answer 17

• A rare but serious condition that occurs when the bundle of nerves at the lower end of the spinal cord, called the cauda equina, is compressed or damaged
• The cauda equina is responsible for transmitting nerve signals to and from the lower limbs, pelvic organs, and lower parts of the body.

Question 18

What are the symptoms of cauda equina?

Answer 18

• It is a surgical emergency

1) LBP; sciatica

2) Saddle anesthesia (numbness in the perineal area)

3) Urinary & Fecal incontinence

4) Unilateral or bilateral lower extremity motor and sensory loss

Question 19

What is the treatment of cauda equina syndrome?

Answer 19

Urgent Surgical decompression of the compressed nerve roots (Often by the removal of the compressing structure (e. g: herniated disk))