Examination of SPINE

Exposure

Clothed only in underpants

Look

1. Gait Normal walking

wide base gait – cervical myelopathy waddling gait – proximal myopathy

Walking on tip toe – S1 weakness Walking on heels – L5 weakness

2. Standing(a)Look from the side

i. normal spine> cervical lordosis> thoracic kyphosis> lumbar lordosis

ii. Increased kyphosis (posterior convexity of the spine)

> senile kyphosis (with osteoporosis, osteomalacia or pathological

fracture)> Scheuermann’s disease

(osteochondritis involving one or more of the

vertebrae)> ankylosing spondylitis

iii. Gibbus (angular kyphosis)> fracture> tuberculosis of the spine> congenital abnormality

iv. Lumbar curvature> flattening or reversal of lumbar lordosis :

- prolapsed intervertebral disc- osteoarthritis of the spine- infection of vertebral bodies- ankylosing spondylitis

> increase in lumbar lordosis- may be normal (esp. in women)- spondylolisthesis- secondary to increased thoracic

curvature or to flexion deformity of the hips

(b) Look from behindi. listing of trunk (due to muscle spasm)ii. Scoliosis (lateral curvature of spine)

- postural : scoliosis disappears with forward flexion of the spine- structural : scoliosis persists with

forward flexion of the spine and a rib hump presents

iii. Shoulder tiltiv. Pelvic tilt

v. Skin changes over the spine- hair tuft (spina bifida)- sinus - colour changes or pigmentation (neurofibroma)- scar

vi. Swellingvii. Prominent crease of the trunkviii. Wasting of glutei, hamstrings and calf

muscles

Feel

along the spinous process, looking for tenderness

paravertebral muscle spasm sacro-iliac joint tenderness step deformity (spondylolisthesis)

- Slide the fingers down the lumbar spine on to the sacrum

- A palpable step at the lumbo-sacral junction

Move Thoracic and Lumbar spine• Flexion

- ask the patient to try to touch his toes- watch the spine for smoothness of movement and any areas of restriction- patients with advanced ankylosing spondylitis have a flat ankylosed spine and all the bending occur at the hips

Lumbar spine excursion test (Schober’s method)

- Mark 2 points 10cm apart at the midline of lumbar spine

- Anchor the top of the tape with a finger and ask the patient to flex as far as he can

- Measure the increase in the distance between the 2 points which indicate lumbar excursion

- Normal excursion = 5 cm or more

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2. Extension- ask the patient to arch his back- assist him by steadying the pelvis and pulling back on the shoulder- normal : 30°

3. Lateral flexion- ask the patient to slide the hands down the side of each leg in turn- record the point reached from the floor or- measure the angle- normal : 30-45°

4. Rotation - patient seated to fix the pelvis or pelvis fixed by examiner- ask the patient to twist round to each side- normal : 45°

Cervical spine1. Flexion

- ask the patient to bend the head forwards- chin should be able to touch the chest- normal : 80°

2.Extension- ask the patient to look up and back- normal : 50°

3. Lateral flexion- ask the patient to touch his shoulder with the ear- involve atlanto-axial and atlanto-occipital joints- normal : 45°

4. Rotation - ask the patient to look over his shoulder- normal : 80°- restricted and painful in cervical spondylitis

Neurological Examination

UPPER LIMB1. Tone hypertonia : UMNL normotonia hypotonia : LMNL

2. Power i. Shoulder

- abduction : C5,C6- adduction : C6,C7,C8

ii. Elbow- flexion : C5,C6- extension : C7,C8

iii. Wrist- flexion : C6,C7- extension : C7,C8

iv. Fingers- flexion : C7,C8- extension : C7,C8- abduction : C8,T1- adduction : C8,T1

3. Reflex - biceps jerk : C5,C6- triceps jerk : C7,C8- brachioradialis (supinator) jerk : C5,C6

4. SensationC5 – lateral armC6 – lateral forearm

- thumb & index fingerC7 – middle fingerC8 – ring&little fingerT1 – medial arm

LOWER LIMB1. Tone hypertonia : UMNL normotonia hypotonia : LMNL

2. Power i. Hip

- flexion : L2,L3- extension : L5,S1,S2- abduction : L4,L5,S1- adduction : L2,L3,L4

ii. Knee- flexion : L5,S1- extension : L3,L4

iii. Ankle- plantar flexion : S1,S2- dorsiflexion : L4,L5

iv. Tarsal joint- eversion : L5,S1- inversion : L5,S1

3. Reflex- knee jerk : L3,L4- ankle jerk : S1,S2- plantar reflex : L5,S1,S2

4. SensationL1 – groinL2 – anterior thighL3 – anterior kneeL4 – medial legL5 – lateral leg

- medial of foot dorsumS1 – lateral of foot dorsum

- heel and foot soleS2 – posterior leg and thigh

Special Tests

1. Straight leg raising test- do on normal limb 1st- raise the leg from the couch with the knee

extended until the patient experiences pain (over the back & may radiate to the lower limb)

- Distribution of the pain indicating the involved nerve root

- Positive if the angle < 60°- Cross sciatic tension : severe root irritation

(pain on the affected side when raising the unaffected leg)

2. Sciatic Stretch Test- Following SLR test- Drop the limb about 10° to relieve tension

on the irritated nerve root- Dorsiflex the ankle to reproduce the same

pain

3. Femoral Stretch Test - For lumbar root

sensitivity- Patient should be

prone- Flex the patient’s knee

and lift the hip into extension

- Pain may be felt in front of the thigh and in the back