Module 15: Advanced Paediatric Spinal

Question 1

What are the 10 steps for motion palpation of the Lumbopelvic spine?

Answer 1

The 10 steps?
1. L5 flexion and Ext
2. Si flexion
3. SI extension
4. L5 rotation
5. L5 LF
6. SI internal and external Rotation
7. S2-4 Flexion
8. Connective Tissue
9. Neurology
10. Compensation patterns

The Lumbar Spine
1. L1-4 Flexion and Extension
2. L1-4 Rotation
3. L1-4 Lateral flexion

Question 2

Step 1
L5 assessment part 1
Identify kinesiopathology at L5/S1 in flexion and extension (X-axis).
Interpretation

Answer 2

Loss of flexion: L5 or anterior sacrum
Loss of extension: Posterior sacrum
Normal: Check innominates, pubis, sacral segments, lower extremities, upper cervical & cranial

Question 3

Step 2
SI joint assessment part 1

Examine the sacroiliac joints in extension
Interpretation
When L5/S1 flexion is lost:

Answer 3

Examine the sacroiliac joints in extension
Interpretation
When L5/S1 flexion is lost:

SI extension will be normal when L5 is subluxated. Proceed to step 4 to quantify the Y & Z-axis vectors.
SI extension will be impaired on the side of the anterior sacrum. Extension will be impaired at both SI’s when the sacrum is base anterior

Question 4

Step 3
SI joint assessment part 2
Examine the sacroiliac joints in flexion (X- axis)
Interpretation
When L5/S1 extension is lost:

Answer 4

SI flexion will be impaired on the side of the posterior sacrum.
Flexion will be impaired at both SI’s when the sacrum is base posterior

Question 5

Step 4
L5 assessment part 2
Define L5/S1 vectors in Y-axis rotation when there is loss of flexion at L5/S1 and normal SI movement
Interpretation

Answer 5

Impaired movement with right pelvic rotation implies a spinous right fixation and with left pelvic rotation a spinous left fixation

Question 6

Step 5
L5 assessment part 3
Define L5/S1 vectors in Z-axis rotation when there is loss of flexion at L5/S1 and normal SI movement
Interpretation

Answer 6

Impaired movement to either side implies an open wedge between L5 and S1 on that side

Question 7

Step 6
SI joint assessment part 3
Define SI rotation when there is loss of flexion or extension with normal L5/S1 movement
Interpretation

Answer 7

Impaired internal rotation implies an external fixation (Ex) and impaired external rotation implies an internal rotation fixation (In)

Question 8

Step 7
Sacral segment assessment
Examine the individual sacral motion segments starting at S1/S2 and moving to S4/S5
Interpretation

Answer 8

Impaired movement in flexion implies posteriority of the lower component of the motion segment being examined.

Question 9

Step 8 Coccyx assessment
Examine the individual coccyx motion segments
Interpretation

Answer 9

Impaired movement in flexion implies posteriority of the lower component of the motion segment being examined.

Question 10

Step 9
Connective tissue response

Answer 10

Examine the point specific connective tissue and muscle locations related to the vectors of kinesiopathology identified in steps 1-7.
Pain is indicated by an involuntary extensor response, spontaneous pupillary constriction, facial wincing, crying or a change in the pitch of the cry.

Question 11

Step 10
Neurology and Compensation patterns

Answer 11

Elicit the muscle stretch reflexes at L4 and S1 in addition to the perianal reflex and the cremasteric reflex in boys
Identify the compensation pattern associated with the subluxation vectors

Question 12

Summarise the Pelvic Assessment in your mind and on paper

Answer 12

Question 13

Anterior sacrum
What are the six main postural and spinal motion compensation responses when an anterior sacrum subluxation is present?

Answer 13

• Increased lumbar & cervical lordosis
• Craned neck posture
• Loss of lateral flexion at the upper cervical complex, often bilaterally
• Loss of rotation at the upper cervical complex, often bilaterally
• Hypermobility at C0/C1 along the long axis of the occipital condyles, invariably bilateral
• Contralateral hamstring hypertonicity

Question 14

Posterior sacrum
What are the five main postural and spinal motion compensation responses when a posterior sacrum subluxation is present?

Answer 14

• Decreased lumbar & cervical lordosis
• Craned neck posture
• Loss of lateral flexion at the upper cervical complex, often bilaterally
• Loss of rotation at the upper cervical complex, often bilaterally
• Hypermobility at C0/C1 along the long axis of the occipital condyles, invariably bilateral

Question 15

L5 Subluxation
What are the three main postural and spinal motion compensation responses when a L5 subluxation is present?

Answer 15

1. Decreased lumbar & cervical lordosis
2. Decreased A-P &/or P-A glide in the hip on the side of the open wedge
3. Hypermobility at L4/L5 in flexion

Question 16

Anterior innominate (AS?)
What are the four main postural and spinal motion compensation responses when an anterior innominate subluxation is present?

Answer 16

1. Decreased lumbar & cervical lordosis
2. Low iliac crest ipsilaterally
3. Elevated gluteal bulk ipsilaterally
4. Elevated SI “dimple” ipsilaterally

Question 17

Posterior innominate
What are the six main postural and spinal motion compensation responses when a posterior innominate subluxation is present?

Answer 17

1. Increased lumbar & cervical lordosis
   What are the six main postural and spinal motion compensation responses when a posterior innominate subluxation is present?
2. Elevated iliac crest ipsilaterally
3. Low gluteal bulk ipsilaterally
4. Low SI “dimple” ipsilaterally
5. Involuntary knee flexion ipsilaterally
6. Decreased A-P glide in ipsilaterally hip joint
7. Short leg same side as PI prone unless anatomical short leg opposite

Question 18

Pubis
What are the main postural and spinal motion compensation responses when an inferior pubic ramus subluxation is present?

What are the main postural and spinal motion compensation responses when a superior pubic ramus subluxation is present?

Answer 18

• Inferior pubic ramus produces the same compensation pattern as the anterior innominate subluxation
• Superior pubic ramus produces the same compensation pattern as the posterior innominate subluxation

Question 19

Mid lumbar subluxations

• In an infant or child, what is the best clinical indicator of a subluxation affecting L3 or L4?
• When motion palpating the lumbar spine in infants, toddlers and pre-schoolers is it easier to palpate hypo or hyper mobility?
• Where is the hypermobility found?

Answer 19

• In an infant or child, what is the best clinical indicator of a subluxation affecting L3 or L4?
• Presence of a crossed adductor response after 6 months of age. Usually ipsilateral to the lumbar subluxation
• When motion palpating the lumbar spine in infants, toddlers and pre-schoolers is it easier to palpate hypo or hyper mobility?
• Hypermobility
• Where is the hypermobility found?
• At the level above the subluxation

Question 20

• What are the six main steps involved in the assessment and correction of each subluxation?

Answer 20

1. Define the vectors of kinesiopathology
2. Define the associated hypermobility
3. Define the neurology of the VSC
4. Define the connective tissue pain patterns
5. Provide the adjustment
6. Confirm the correction of the hypomobility, hypermobility and neurology

Question 21

• What are the most common pelvic subluxations in infants?
• How would you correct an anterior sacral subluxation?

Answer 21

• The most common pelvis VSCs are: BAS, R/LAI Sacrum, BPS, PI-L/R Sacrum, PI S2-4.
• The anterior sacral component can only be corrected by using a Logan Contact

Question 22

• What are the four main patient factors you need to consider when deciding how to adjust a child?

Answer 22

• Technique used needs to take into account
  1. Age of patient
  2. Size of patient
  3. Degree of muscular development
  4. Ability to relax

Question 23

• What are the main causes of an Anterior Sacrum subluxation at any age?
• What the main causes of sacral segment subluxations in the ambulatory pre-schooler?

Answer 23

• What are the main causes of an Anterior Sacrum subluxation at any age?
• Viscerosomatic reflexes  Food allergies
   Chemical reactions
   Infections
   Dysbiosis  Hormones
• Falling over
• What the main causes of sacral segment subluxations in the ambulatory pre-schooler?

Question 24

Clinical case 1 – 6 moa What is your diagnosis

• The lumbosacral junction is restricted in * both flexion and extension.
• The left SI joint is restricted in extension
• The right SI joint is restricted in flexion
• The left S1 is +2
• The right S1 is 0
• The right S1-2 intervertebral space is restricted in flexion

Answer 24

Rotated sacrum
 LAI/PR sacrum subluxation
* PR S2 subluxation

Question 25

Clinical case 2 – 6 moa What is your diagnosis * The lumbosacral junction is restricted in flexion. * The left SI joint is restricted in extension * The right SI joint is restricted in extension * The left S1 is +1 * The right S1 is +1

Answer 25

* Base anterior sacrum

Question 26

Clinical case 3 – 6 moa What is your diagnosis * The lumbosacral junction is restricted in extension. * The left SI joint is restricted in flexion * The right SI joint is normal * The left S1 is +1 * The right S1 is +3

Answer 26

* Left posterior sacrum

Question 27

Clinical case 4 – 6 moa What is your diagnosis * The lumbosacral junction is restricted in extension. * The left SI joint is restricted in flexion * The right SI joint is restricted in flexion * The left S1 is +1 * The right S1 is +1

Answer 27

Base posterior sacrum

Question 28

Biomechanical stress and the cervical spine * How does biomechanical stress on the spine of children change as they get older?

Answer 28

* Birth stress on the fetal cervical spine is focused on the C0-C1 level * Cervical spine injuries in children usually occur in the upper cervical spine from the occiput to C3. * The fulcrum of motion in the cervical spine in infants and toddlers is at the C2-C3 level * As the child grows and the fulcrum descends the cervical spine the subluxation pattern also change with C3-4 evident in pre-schoolers and primary school aged children * In the secondary school aged child the fulcrum is at the C5-C6 level

Question 29

* What are the most common subluxations found in the cervical spine of infants? List from most common to least What are the most common subluxations found in the cervical spine of toddlers and pre-schoolers? What are the most common subluxations found in the cervical spine of school aged children?

Answer 29

Question 30

Anterior occiput What are the main postural and spinal motion compensation responses when an anterior occiput subluxation is present in an older child? What are the main postural and spinal motion compensation responses when an anterior occiput subluxation is present in an infant?

Answer 30

* Reduced cervical lordosis * Craned neck posture * Hypermobility at axis/C3 in flexion * Short leg in the supine position on the same side as the subluxation * Head tilt away from the side of subluxation Infant 1. Preference for head extension 2. Preference for turning head to the opposite side with head tilt usually to the same side

Question 31

Anterior occiput What are the five main behavioural responses and history findings when an anterior occiput subluxation is present in an infant? What are the six main signs of vagal nerve involvement in an infant?

Answer 31

1. Dislike of lying supine unless head turned to side opposite anterior occiput subluxation 2. Dislike of car seat, usually until car moving 3. Dislike of clothing being pulled over head 4. Dislike of nappy change when done supine 5. Pulls off when breast feeding and arching Vagal nerve irritation 1. Vomiting 2. Reflux 3. Regurgitation 4. Dribbling 5. Choking 6. Gagging

Question 32

Anterior occiput What are the typical main examination findings when an anterior occiput subluxation is present in an infant? Can you think of nine?

Answer 32

1. Flat occiput on the opposite side to anterior occiput subluxation 2. Supine positional preference for head rotation away from side of anterior occiput, head extension and lateral flexion of head to the same side. 3. Delay in head control development, increased head lag with pull to sit test 4. Head rotation away from side of anterior occiput and lateral flexion to side of anterior occiput with pull to sitting test 5. Increased or persistent Moro reflex 6. Increased or persistent Galant’s and Perez reflexes 7. Increased head extension when prone 8. Restricted head flexion on side of anterior occiput and restricted upper cervical lateral flexion 9. Possible positive Scapulohumeral reflex on same side 10. Possible blocked nasolacrimal duct on same side 11. Possible eyelid ptosis on the same side 12. Increased gag response to palpation of the hard palate or assessment of suck strength

Question 33

Posterior occiput What are the main postural and spinal motion compensation responses when a posterior occiput subluxation is present in an older child? What are the main postural and spinal motion compensation responses when a posterior occiput subluxation is present in an infant?

Answer 33

* Increased cervical lordosis * Hypermobility at axis/C3 in flexion * Short leg in the supine position on the same side as the subluxation * Head tilt away from the side of subluxation * Infant  Preference for head flexion  Difficult to dry under chin  Increased, often very pronounced, drooling  Head tilt away from side of subluxation

Question 34

Posterior occiput What are the main behavioural responses and history findings when a posterior occiput subluxation is present in an infant? What are the typical main examination findings when a posterior occiput subluxation is present in an infant? Can you think of seven?

Answer 34

Infant  Preference for head flexion  Difficult to dry under chin  Often red, wet skin rash affecting anterior neck  Increased, often very pronounced, drooling – needs super sized plastic backed bib  May dislike prone position Examination findings  Head tilt to side opposite posterior occiput  Holds head flexed  Poor head extension when prone  Increased ability to flex neck/head with pull to sitting test  Increased drooling  Rash anterior neck and chest due to drooling  Difficult to palpate anterior neck as difficult to lift chin

Question 35

Atlas What are the main postural and spinal motion compensation responses when an atlas subluxation is present in an older child? What is the most common atlas subluxation listing in an infant and toddler? What is the most common atlas subluxation listing in a school aged child?

Answer 35

What are the main postural and spinal motion compensation responses when an atlas subluxation is present in an older child? 1. Decreased cervical lordosis with AS 2. Increased cervical lordosis with AI 3. Ipsilateral short leg when laterality is the dominant factor 4. Contralateral short leg when rotation is the dominant factor 5. Head tilt away from the side of anterior rotation or towards the side of posterior rotation What is the most common atlas subluxation listing in an infant and toddler? * AI and posterior atlas * AS and posterior atlas What is the most common atlas subluxation listing in a school aged child? * Viscero-somatic issues such as food allergies

Question 36

Atlas What are the main history and examination findings when an atlas subluxation is present in an infant? Which part of head rotation will an atlas subluxation affect? The first 45 degrees or the second 45 degrees?

Answer 36

Atlas What are the main history and examination findings when an atlas subluxation is present in an infant? History 1. Fussy breast feeding with the infant coming off and shaking the head 2. Favours head rotation to side of posterior atlas Examination 1. Presence of ipsilateral scapulohumeral reflex 2. Grossly restricted head rotation to side opposite posterior atlas subluxation Which part of head rotation will an atlas subluxation affect? The first 45 degrees or the second 45 degrees? The atlas mostly rotates on C2 after C2-7 levels have ceased rotating and this occurs around 40-45 degrees of head rotation Atlas subluxation will show with reduced rotation after about 45 degrees

Question 37

What are the main postural and spinal motion compensation responses when an atlas subluxation is present in an older child? What is unusual about C2?

Answer 37

1. Hypermobility at C0/C1 along the long axis of the occipital condyle 2. Head tilt away from the side of the open wedge What is unusual about C2? What is unusual about C2? * Axis is characterized by a high level of atypical subluxation patterns such as ESL/ESR C2, PI C2

Question 38

Step 1 Upper cervical lateral flexion Identify kinesiopathology at the upper cervical complex in lateral flexion Interpretation

Answer 38

Loss of lateral flexion unilaterally implies a subluxation on that side (except AS C0 in infant) Loss of lateral flexion bilaterally implies an atypical upper cervical subluxation or a compensation response

Question 39

Step 2 Occiput assessment Examine long axis condylar movement in both flexion & extension Interpretation When flexion is lost: AS occiput When extension is lost: PS occiput

Answer 39

yaya

Question 40

Step 3 Axis flexion Examine the axis/C3 motion segment in flexion (X-axis) Interpretation

Answer 40

Flexion will be decreased when the axis is subluxated and yields the posterior (P) component of the listing. The S/-I component is determined by Step 1.

Question 41

Step 4 Axis rotation If flexion is impaired at axis/C3, examine the motion segment in rotation (Y-axis) Interpretation

Answer 41

Impaired movement with right head rotation implies a spinous right fixation and with left head rotation a spinous left fixation Step 5 Cervical spine rotation Determine the degree of gross cervical rotation Interpretation The atlas will be deemed to be anterior on the side to which rotation is lost or posterior on the opposite side

Question 42

Step 6 Short leg assessment Determine the side of the short leg in the supine position Interpretation

Answer 42

The short side corresponds to the side of occiput subluxation, axis wedging and atlas subluxation provided laterality is the dominant kinesiopathological factor. The short side will be contralateral to the side of atlas subluxation when rotation is the dominant kinesiopathological factor

Question 43

Step 7 Posture assessment Examine the head posture in the erect position Interpretation

Answer 43

The head will tilt away from the side of subluxation in all listings except the posterior atlas subluxation in which rotation is the dominant kinesiopathological factor and the AS occiput in infants

Question 44

See Summary of Cervical Spine assessment

Answer 44

Question 45

Assessment of the cervical spine C3-7

Answer 45

* Assess the spinous process movement of each level in flexion * Assess the spinous process movement of each level in lateral flexion * Assess the spinous process movement of each level in rotation * Look for compensatory hypermobility at the level above * Determinethelisting  PL/PR PLS/PRS PLI/PRI * Testtheneurology  Muscle stretch reflexes of the upper extremity  Muscle strength testing  Sclerotomes

Question 46

Clinical Identification and correction of the Subluxation * What are the six main steps involved in the assessment and correction of each subluxation?

Answer 46

1. Define the vectors of kinesiopathology 2. Define the associated hypermobility 3. Define the neurology of the VSC 4. Define the connective tissue pain patterns 5. Provide the adjustment 6. Confirm the correction of the hypomobility, hypermobility and neurology

Question 47

* What are the most common cervical spine subluxations in infants? * What subluxation pattern of the upper cervical spine produces a marked head tilt without much rotation?

Answer 47

* What are the most common cervical spine subluxations in infants? * The most common cervical VSCs are:  ASLS/ASRS CO  AILP/AIRP C1 * What subluxation pattern of the upper cervical spine produces a marked head tilt without much rotation? * AS C0combined with a PS C0 on the opposite side. The AS C0 will be on the side that the head is tilted towards.

Question 48

What are the five main factors you need to consider when deciding how to adjust the cervical spine in a child?

Answer 48

Technique used needs to take into account 1. Age of patient 2. Size of patient 3. Degree of head control 4. Degree of muscular development 5. Ability to relax

Question 49

* How can you assess the upper extremity sclerotomes? * Look for pain response to palpation of the * What nerve root levels can you test? * Above the correspondingly named vertebra * At what anatomical level do cervical spine roots exit the spine? * A patient has a tender left distal radius to palpation, but normal response to palpation of the acromion process and the humeral epicondyles. The radius pain is reduced by head left lateral flexion, head flexion and left rotation: what nerve roots are involved, what is the listing and what is the expected level of the subluxation?

Answer 49

* How can you assess the upper extremity sclerotomes? * Look for pain response to palpation of the  Acromion process C5  Distal radius C6  Medial and lateral epicondyle of the humerus C7 * What nerve root levels can you test? * Above the correspondingly named vertebra  C4 nerve root exits between C3 and C4 vertebrae * At what anatomical level do cervical spine roots exit the spine? * A patient has a tender left distal radius to palpation, but normal response to palpation of the acromion process and the humeral epicondyles. The radius pain is reduced by head left lateral flexion, head flexion and left rotation: what nerve roots are involved, what is the listing and what is the expected level of the subluxation? * Left C6 nerve root irritation * PLSC5 * C6 Cervical nerve roots exits between C5 and C6 vertebrae

Question 50

Sclerotomes of the upper extremity - cases A patient has a tender right distal radius to palpation and pain over the right medial humeral epicondyle, but normal response to palpation of the acromion process. The radius and epicondyle pain are reduced by head left lateral flexion, head flexion and left rotation: what nerve roots are involved, what is the listing and what is the expected level of the subluxation? * A patient has a tender left distal radius to palpation, but normal response to palpation of the acromion process and the humeral epicondyles on the left. The radius pain is reduced by head right lateral flexion, head flexion and left rotation. There is also tenderness over the right acromion which is relieved by head flexion, right lateral flexion and right rotation : what nerve roots are involved, what is the listing and what is the expected level of the subluxation?

Answer 50

1. * Right C6 and C7nerve root irritation * PLS C5 * C6 Cervical nerve roots exits between C5 and C6 vertebrae 2. * Left C6 and right C5 nerve root irritation * PLI C5 and PRS C4

Question 51

* A patient has a tender left distal radius to palpation, but normal response to palpation of the acromion process and the humeral epicondyles on the left. The radius pain is not significantly reduced by head position change but is reduced by arching the lumbar spine. There is also tenderness over the right acromion which is not relieved by head position change but is reduced by flexing the lumbar spine: what nerve roots are involved, what is the listing and what is the expected level of the subluxation?

Answer 51

* Left C6 and right C5 nerve root irritation * Left posterior sacrum * Right anterior sacrum Dx: Rotated sacrum

Question 52

The Paediatric Thoracic Spine

Answer 52

pg 77