Spine examination Flashcards
In what general order should you perform the spine exam?
Look: Posterior and lateral
Feel: Bony structures, paraspinal muscles
Move: Cervical, thoracic, lumbar
Sensation: Cervical, thoracic, lumbar
Power/motor function by resisted movements: Cervical, thoracic, lumbar
Special tests: Straight leg raising, femoral nerve stretch
When looking at the patient’s back from posterior view, give examples of what abnormalities on the skin to look for?
Muscle wasting
Symmetry/asymmetry of shoulder muscles
Bruising
Scarring
Skin discolouration/changes
Pelvic tilt
Why should you look for spinal muscle wasting?
Could indicate disuse atrophy, which is caused by underlying pathology
When looking at the patient’s back from the side, what abnormality should you look for in the cervical spine?
Cervical lordosis
Pushes your neck further forward than it should be or usually is
When looking at the patient’s back from the side, what abnormality should you look for in the thoracic spine?
Thoracic kyphosis
excessive curvature in the thoracic spine that leads to a rounded upper back
When looking at the patient’s back from the side, what abnormality should you look for in the lumbar spine?
Excessive lumbar lordosis: Swayback
Excessive inward curve of the lumbar spine
When looking at the patient’s back from behind, what abnormality in the spine shape should you look for?
Scoliosis
Abnormal lateral curvature of spine
What bony structures should you feel first, and in which parts of the spine?
Feel spinous processes of each vertebra
From atlanto-occipital joint to SI joints
Give 3 possible underlying pathologies of pain upon palpation of spinous processes?
Vertebral fractures
Baastrup syndrome: low back pain characterized by interspinous bursitis and other degenerative changes of the bones and soft tissues where adjacent spinous processes in the lumbar spine rub against each other
Subluxation/dislocation causes off-set centre of processes
After feeling the spinous processes, what should you palpate in the lumbosacral area?
Posterior iliac spine
Dimples of Venus (top of sacroiliac joints)
How can you identify the sacroiliac joints and posterior iliac spine to palpate?
Use surface anatomy of lumbosacral area
Dips in low back are dimples of Venus, which is the tip of SI joint and near posterior iliac spine
Why is it important to palpate the dimples of Venus?
Pain can indicate SI joint dysfunction
which can be caused by underlying pathologies such as spinal OA, AS, infection in joint
What is meant by paraspinal muscles, and which 3 are they?
Contract to cause main actions of spine: Extension, rotation, lateral flexion
Erector spinae muscles: Iliocostalis, Longissimus, Spinalis
What muscles should you palpate in the spine, after feeling spinous processes and dimples of Venus?
Paraspinal (erector spinae) muscles
Erector spinae muscles: Iliocostalis, Longissimus, Spinalis
What 4 actions of the cervical spine should you test?
Flexion
Extension
Lateral flexion
Rotation
Before testing movement of the cervical spine, what position should the patient be in?
Sitting down or supported
They can become unstable
How do you test flexion of the cervical spine?
Ask patient to touch chin towards chest
How do you test extension of the cervical spine?
Ask patient to tilt head backwards to look at ceiling
How do you test lateral flexion of the cervical spine?
Ask patient to tilt head to side and bring ear to ipsilateral shoulder
How do you test rotation of the cervical spine?
Ask patient to turn head to look over each shoulder
What action do you test for in the thoracic spine?
Rotation: Ask patient to sit on bed with arms crossed across chest, the ask patient to rotate to each side as far as it comfortable
When testing thoracic spine rotation, why must you ask patient to sit and cross arms?
To fix pelvis
What 3 movements do you test in the lumbar spine?
Flexion
Extension
Lateral flexion
What special test do you use to test flexion of lumbar spine?
Schober’s test
Mark 10cm superiorly from the ‘Dimples of Venus’ and 5cm inferiorly. Place your fingers on these areas. Ask patient to touch their toes
This gap between the 2 marks (which is currently 15cm), should increase by >5cm. Anything less than this indicates reduced lumbar flexion
How can you test flexion and extension of lumbar spine without using Schober’s test?
Ask patient to bend to touch their toes, put 2 of your fingers on patient’s lumbar spine:
Lumbar flexion: When patient bends forwards, your fingers move apart
Lumbar extension: When patient stands straight, your fingers move together
How do you test lateral flexion of lumbar spine?
Ask patient to run each hand down lateral side of adjacent leg
Where do you swipe with a cotton wool to test sensation of C5 dermatome?
Lateral aspect of the lower edge of the deltoid muscle: “regimental badge”
Where do you swipe with a cotton wool to test sensation of C6 dermatome?
Thumb
or first dorsal web space
Where do you swipe with a cotton wool to test sensation of C7 dermatome?
Palmar surface of middle finger
Where do you swipe with a cotton wool to test sensation of C8 dermatome?
Palmar side of little finger
Where do you swipe with a cotton wool to test sensation of T1 dermatome?
Medial surface of Cubital fossa (Medial surface of arm just proximal to medial epicondyle)
Where do you swipe with a cotton wool to test sensation of C4 dermatome?
Bottom of neck
or top of shoulders
Where do you swipe with a cotton wool to test sensation of C3 dermatome?
Top of neck
or bottom half of back of skull
Where do you swipe with a cotton wool to test sensation of C2 dermatome?
Top half of back of skull
How do you test power of the myotome C5, and which muscle does this isolate?
Deltoid
Ask patient to bend elbows and bring abduct shoulder to 90 degrees ‘chicken arms’
Push down on tops of their upper arm, tell them to resist
How do you test power of the myotome C6 in 2 ways, and which 2 muscles does this isolate?
- Elbow flexors: biceps brachii, coracobrachialis and brachialis
Ask patient to flex elbows, try to pull their forearms towards you and tell them to resist (stabilise shoulder joint by holding elbow)
- Wrist extensors: Tell patient to make fist and point wrist to ceiling, you push down
How do you test power of C7 myotome in 3 ways, and which muscle is isolated?
- Triceps brachii
Ask patient to flex elbows, try to push their forearms towards them and tell them to resist (stabilise shoulder joint by holding elbow)
- Wrist flexors: Tell patient to make fist and point wrist to floor, you pull up
- Ask the patient to hold their fingers out straight whilst you apply downwards resistance: “Hold your fingers out straight and don’t let me push them down.”
How do you test power of C8 myotome?
Finger flexion: Tell patient to grip your fingers in their fist and to not let you pull out of grip
How do you test power of T1 myotome?
Finger abduction: Ask patient to spread out fingers and not let you push them together
Where do you swipe with a cotton wool to test sensation of L1 dermatome?
Inguinal area (area between torso and thigh) (groin)
or trochanter
Where do you swipe with a cotton wool to test sensation of L2 dermatome?
Middle of anterior thigh
Where do you swipe with a cotton wool to test sensation of L3 dermatome?
Medial epicondyle of femur
Where do you swipe with a cotton wool to test sensation of L4 dermatome?
Medial malleolus
or medial surface of calf
Where do you swipe with a cotton wool to test sensation of L5 dermatome?
Middle of foot dorsum (upper surface) to 2nd, 3rd, 4th toes
Where do you swipe with a cotton wool to test sensation of S1 dermatome?
Lateral surface of foot
How do you test power of L1/L2 myotome?
Ask the patient to raise their straight leg off the bed and apply downward resistance over the anterior thigh
“Lift your leg off the bed and don’t let me push your leg down.”
How do you test power of the L3 myotome?
Knee extension: Ask patient to lie on bed and flex their knee to 90 degrees, ask them to try to extend knee whilst you push on anterior calf
“Try and straighten your leg whilst I try to stop you.”
How do you test power of the L4 myotome?
Dorsiflexion
Ask patient to lie on back with straight legs, then to point foot/toes towards their face whilst you push down on dorsum
“Put your legs flat on the bed, point your foot towards your face and don’t let me push your foot down.”
How do you test power of the S1 myotome?
Plantar flexion
“Put your legs flat on the bed, point your foot down like pressing on a pedal and don’t let me push your foot up.”
How do you test power of L5 myotome?
1st/great toe extension
With the patient’s legs still flat on the bed, ask them to extend their big toe and resist you trying to push it down
“Point your big toe up towards your head and don’t let me push it down.”
What special test should you perform to test for sciatica (L4,L5,S1,S2,S3)?
Sciatic stretch/straight leg raising (SLR) test
Flex hip and raise straight leg
Positive: patient feels pain below knee on posterior calf between 30 and 70 degrees hip flexion, suggests sciatica
Negative: patient doesn’t feel pain below knee on posterior calf between 30 and 70 degrees hip flexion, doesn’t suggest sciatica
What special test should you perform to test for femoral nerve root impingement (L2,L3,L4)?
Femoral nerve stretch test
Flex knee while patient is lying prone (face-down)
Positive: flexion causes anterior thigh pain, suggests nerve root impingement
Negative: flexion doesn’t cause anterior thigh pain, doesn’t suggest nerve root impingement
If further examination was needed, what are the 2 most important investigations?
MRI scan of spine
Examination of shoulder and hip joints
