examination of spine for graduates and post graduates

1. EXAMINATION OF SPINE
Presenter - Dr. Guru prasad (DNB ORTHO )

2. Introduction

3. Vertebral
Body
Pedicle
Lamina
Superior
Articular
Process
Spinous
Process
Transverse
Process
Vertebral
Foramen
Vertebral Structures

4. Vertebral Structures
Superior
Articular
Process
Inferior
Articular
Process
Pars
Zygapophyseal
Joint
(Facet Joint)

5. Vertebral Structures
• Pedicle notches
Slight
Notch
Deep
Notch
Intervertebral
Foramen
• INTERVERTEBRAL FORAMEN
through which the spinal nerve roots
leave the spinal cord

6. • Anterior Arch
Vertebral Arches
Comprised of:
– Vertebral body
– Anterior 1/3 of the pedicles
• Posterior Arch
Comprised of:
– Posterior 2/3 of the pedicles
– Lamina
– Processes

8. Arteries of the Thoracic and Lumbosacral Regions
Vertebral
artery Aortic arch
Ascending
aorta
Descending
aorta
Thoracic
segmental
arteries
Abdominal
aorta
Bifurcation
of the aorta Lumbar
segmental
External iliac arteries
artery (left &
right) Internal iliac
artery (left &
Femoral artery right)
(left & right)

9. Batson’s Plexus
The AZYGOS SYSTEM is a large
network of veins draining blood from the
intestines and other abdominal organs
back to the heart. The segmental veins
drain into the azygos vein located on the
right side of the abdomen, or into the
hemiazygos vein located on the left side.
The azygos system also
communicates with a valveless venous
network known as BATSON’S PLEXUS.
When the vena cava is partially or totally
occluded, Batson’s plexus provides an
alternate route for blood return to the
heart.
The vessels of Batson’s plexus may
be referred to as epidural veins
Batson’s
plexus

10. • C7 – Prom. Spinous
Process
 T3- Level with Medial
Scapular Spine
 T7 – Inferior angle of
scapula
 L2 – Lowest Rib
 L4 – Iliac Crest

11. Spinal Nerve Structures
Spinal Cord
• Contained in epidural space
• Network of sensory and motor
nerves
• Firm, cord-like structure
Foramen
magnum
• Extends from foramen magnum to L1
• Terminates at the conus
medularis
• The cauda equina begins
below L1
• Filum terminale extends from
conus medularis to the coccyx
Conus
medularis
Cauda
equina

12. Spinal Nerves
Spinal
cord
Epidural
space
Dura mater and
Arachnoid layers
Subarachnoid
space
Dorsal root
Ventral
root
Dorsal root
ganglion
Peripheral
nerve

13. Meninges
Within the spinal canal, the spinal cord is surrounded by the EPIDURAL
SPACE, filled with fatty tissue, veins, and arteries. The fatty tissue acts as a shock
absorber.
The spinal cord is covered by MENINGES which has three layers.
Dura mater
Subdural space
Arachnoid
layer
Subarachnoid
space: filled
with CSF
Pia mater

16. Functions of spine
• Spinal cord encasement
• Weight transmission
• Posture
• Vital organs back support
• Muscles attachment

17. Common conditions affecting the
spine

19. Clinical examination of spine

20. History

21. Age Disorders
Child spina bifida , Potts disease , congenial scoliosis
Adolescent Idiopathic scoliosis,schurmann’s disease , mechanical back pain
,infections
Young adults PIVD , fracures ,ankylosing spondylosis ,tuberculosis
Middle age Spondylosis, spondylolysthesis, tumors , PIVD
Elderly Osteoporosis ,metastasis ,spondylosis
sex disorder
Male ankylosing spondylitis ,prolapse intervertebral
disc , osteoarthritis
Female psychogenic backache,osteomalacia
ligamentous strain

22. • 4.pain-
A)Site-cervical region ,dorsal region, in the lumbodorsal region or lumbar region , in
the lumbosacral region or in the sacral region.
B)Mode of onset-whether the pain started immediately after trauma or lifting weight
or during strenous exercies as seen in prolapsed intervertebral disc
C)Nature of pain-
Stabbing –pivd
Continous and throbbing type in osteomyelitis
Intermittent pain –spondylolisthesis
Dull ache in pott’s disease
D)Radiation
E)aggravating factors
F)relieving factors-rest
G)Positional variance
H)Rest pain

23. • Deformity-localized/diffuse ,onset progression
• Swelling –site ,onset,1st noticed, duration, progression
• stiffness of the back
• Weakness –
unilateral/bilateral
motor /sensory
sudden /insidious
duration progression
bowel/bladder involvement –early/late
• Restriction of ROM
• Abnormality in walking
• Disability

24. Ask for…

25. Past history

26. Personal history

27. Family history

28. General examination

29. Inspection
Standing
(a) Look from the side
i. normal spine
> cervical lordosis
> thoracic kyphosis
> lumbar lordosis

30. 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

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

32. . 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 pregnant women)
- spondylolisthesis
- secondary to increased thoracic curvature
or to flexion deformity of the hips

35. Look from behind
i. 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 tilt
iv. Pelvic tilt

36. v. Skin changes over the spine
- hair tuft (spina bifida)
- sinus
- colour changes or pigmentation (neurofibroma)
- scar
vi. Swelling
vii. Prominent crease of the trunk
viii. Wasting of paraspinal muscles, glutei,
hamstrings and calf muscles

38. Palpation

40. 3.SWELLING-Spina
bifida-meningocele in the sacral or
occipital region
Congenital sacrococcygeal teratoma in
sacrococygeal region

43. MEASUREMENTS
1. Linear measurements
a. From external occipital protrubence to tip of
coccyx
b. Iliocostal distance ( tip off last rib to iliac cest)
c. Segmental measurement
d. Acromiooccipital distance
e. Schober`s test
f. Otto test
2. Chest expansion
3. Limb length discrepancy

44. Cervical spine
Consist of 7 vertebra
8 nerves
Give two plexuses
Cervical plexus ( C1-C5) brachial plexus ( C5-T1)
Phernic ( C3,C4,C5) mucocutanous n (C5-C7)
Lesser occipital (C2) axillary n (C5-C6)
Supraclaviclular ( C3,C4) median n (C5-T1)
radial N (C5-T1)
ulnar n (C8-T1)

45. Cervical spine
History
* acute trauma
History of Falling down , vehicle accident .
Any patient unconious form after heard injury
you should assumed it as cervical spine injury.
ABC, WAIT FOR help , x –ray frontal &
lateral

46. Cervical spine
History
* PAIN :- analysis of pain
Acute ,sub acute ,chronic
Onset ,duration , character , severity ,radiation ,reliving
,aggravating factor
At end of day /at night , other joint affected
*Weakness in upper limb
*Paraesthesia

47. Cervical spine
History
Pain and difficulty turning the head and
neck, examples are:
→ Disease of atlanto-occipital joints
produces pain radiating to the occiput.
→ Spondylosis of the middle and lower
cervical spines causes pain radiating to the
upper border of trapezius, interscapular region,
and the arms.
→ Irritation of the C6 & C7 nerve roots can
give rise to referred pain in the interscapular
region, radial fingers, and thumb.
→ Irritation of C8 can cause pain on the
ulnar side of forearm, ring, and little fingers.

48. Cervical spine
Physical examination:
Look
Observe the posture of the head and neck
and note any abnormality and deformity, e.g.
loss of lordosis.
Feel
→ The midline spinous processes
→ The paraspinal soft tissues
→ The supraclavicular fossae – for cervical
ribs or enlarged lymph nodes
→ The anterior neck structures including the
thyroid

49.  CERVICAL SPINE
 Forward flexion
 Normal : 75 to 90 degrees
 Extension
 Normal : 45 degrees
 Right lateral flexion
 Normal : 45 to 60 degrees
 Left lateral flexion
 Normal : 45 to 60 degrees
 Rotation to right
 Normal : 75 degrees
 Rotation to left
 Normal : 75 degrees

50. Special tests
 Cervical spine :
 Compression test
 Distraction test
 Valsalva test
 Swallowing test
 Adson test

51. COMPRESSION TEST
 Press down upon the top of pt’s
head
 If there is increase pain in
either cervical spine or upper
extremity, note its exact
distribution. So, we can locate
the neurological level
 A narrowing of neural foramen,
pressure on the facet joints or
muscle spasm can cause
increase pain upon
compression

52. DISTRACTION TEST
 Place the open palm of one
hand under the pt’s chin, and
the other hand is upon occiput
 Then, gradually lift (distract)
the head to remove its weight
from the neck
 To demonstrate the effect that
neck traction might have help
in relieving the pain by
decreasing pressure on the
joint capsules around the facet
joints.

53. VALSALVA TEST
 Ask pt to hold his breath and bear down as if
he were moving his bowels
 Then, ask whether he feels any increase in
pain and describe the location
 This test increase intratechal pressure
 If a space occupying lesion, such as a
herniated disc or a tumor present in cervical
canal, pt may develop pain in cervical spine
secondary to increase pressure
 The pain also may radiate to the dermatome
distribution of cervical spine pathology

54. SWALLOWING TEST
 Difficulty or pain upon swallowing
can sometimes caused by cervical
spine pathology such as :
 Bony protuberance
 Bony osteophytes
 Soft tissue swelling due to
hematomas, infection or tumor
in ant portion of cervical spine

55. NAFFZIGER’S TEST
 manual compression of the jugular veins bilaterally. An
increase or aggravation of pain or sensory disturbance
over the distribution of the involved nerve root confirms
the presence of an extruded intervertebral disk or other
mass.

56. LHERMITTE’S SIGN
 This sign detects protrusion of
cervical intervertebral disc or
an extradural spinal tumour
irritating the spinal duramater.
 The patient sits on an
examining table,now the head
of the patient is bent down
passively(flexion of cervical
spine ) and simultaneously the
lower limbs are lifted(flexing the
hip joints) keeping the knees
straight. This will causes sharp
pain radiating down the spine
and to both the extremities.

57. ADSON TEST
 Pull the arm downwards
 Palpate the radial pulse
 Turn the pt’s head to the same side and extend the neck
 Abduct, extend, and laterally rotate the shoulder.
 From this position, have the patient take a deep breath and hold
 Feel the radial pulse
 Fading of the radial pulse indicates positive thoracic outlet obstruction

58. Thoracic spine( T1-T12)
History
→ Commonly, localized spinal pain, examples are:
 Ankylosing spondylitis produces pain in the thoracolumbar region
 Acute thoracic spinal pain may be due to vertebral prolapse due to
malignancy, or infection; especially if there was systemic upset or fever
is present
→ Less commonly, symptoms of paraparesis including sensory loss,
leg weakness, and loss of bladder or bowel control

59. Thoracic spine
Physical examination:
Look
With the patient standing, inspect posture
from behind, the side and the front, noting any
deformity, e.g. rib hump or abnormal curvature.
Feel
→ The midline spinous processes
→ The paraspinal soft tissues
→ If there is increased prominence of one or
more spinous processes implying anterior
wedge-shaped collapse of the vertebral body –
often related to osteoporosis.
Move
Ask the patient to sit with arms crossed, and
to twist round and look at you

60. Lumbar spine
LUMBAR NERVES( L1-L5)
SACRAL NERVES ( S1-S4)
LUMBAR PELUXES ( L1-L4)
illioingunal (L1) , iliohypogastric (L1) ,
genitofemoral (L1-L2), Femoral (L2-L4)
Obuturator (L2-L4)
SACRA L PELUXES
SCIATIC NERVE (L4 –S3)
1- Common peroneal
2- Tibia

61. Lumbar spine
History
→ Low back pain is an extremely common
complaint
→ Sacroilitis produces pain that is referred
down both legs to knees
→ Consider abdominal and retroperitoneal
pathology, e.g. abdominal aortic aneurysm,
pancreatitis, peptic ulcer, renal pathologies.

62. Lumbar spine
Red flag features for acute low back pain:
→ In History:
 Age < 20 yrs or > 55 years
 Recent significant trauma (fracture)
 Pain:
Thoracic (dissecting aneurysm)
Non-mechanical (infection/
tumor/pathological fracture)
Fever ( infection)
Difficult micturition
Fecal incontinence
Motor weakness
Saddle anesthesia
Sexual dysfunction
Gait change ( cauda equina
syndrome)
Bilateral sciatica

63. Lumbar spine
Red flag features for acute low back pain:
→ In Past medical History:
 Cancer ( metastasis.)
 Previous steroid use (osteoporotic
collapse)
→ In Systemic review:
Weight loss/malaise without obvious cause
(e.g. cancer)

64. Lumbar spine
Physical examination:
Look
Examine the patient standing. Look for obvious abnormality such
as decreased/increased lordosis, obvious scoliosis soft tissue
abnormalities such as a hairy patch or lipoma that overlie spina
bifida.
Feel
Palpate the spinous processes and the paraspinal tissues. The
L4/L5 interspinous space is palpable at the level of iliac crests.

65.  Thoracic and lumbar spine
 Forward flexion (Schober’s test)
 Normal : 90 degrees
 Extension
 Normal : 30 degrees
 Lateral flexion to left and right
 Normal : 30 to 45 degrees
 Rotation to left and right
 Normal : 45 degrees

66.  1)flexion-
 adult:- flexion is tested by asking him to lean forward
keeping the knees straight .The clinician places his
hands over the spine to note the movements of the
spinous processes.It must be noted how much of the
movements occurs at the spine and how much the hip
flex.
 children-:-ask him to pick up on object from the
floor.when the spine is rigid the child will stoop bending
his knees and hips keeping the spine straight.while
raising the body he puts his hands successively on the
legs ,knees and thighs as if he is climbing up his own
legs.

67.  2)extension:-
 Adult- patient may be asked to lean backwards. Note the
range of extension movement. This movement mainly
occurs in the lumbar region.

68. • Children- in case of children the patient is laid
on his face.The clinician lifts up his legs in an
attempt to bend the lumbar spine whilst the
other hand fixes the dorsal spine.If the lumbar
spine is affected it cannot be bent but will be
lifted as one piece

69.  3)lateral flexion:- adults are asked to bend sideways
while standing .
 In children these movements are demonstrated by lifting
up the legs as in testing extension and then by carrying
the legs first to one side and then to the other to bend the
spine sideways.
 The other hand of the clinician is placed on the thoracic
spine to detect the movements of the spine.

70. Schober’s test
Schober’s test for forward flexion
1- Erect position.
2- Select 2 bony points (POSTERIOR SUPERIOR
ILLIAC SPINE)
3-Maximum flexion on lumbar with fix knee.
4-the two points should separate by at least a
further 5cm.

71.  4) Rotations:- the patient is always asked to sit down so
as to fix his pelvis.He is then instructed to rotate the trunk
to the right and to the left.
 E. MEASUREMENT- the lengths of the lower limb must
be measured to exclude shortening of any limb as the
cause of scoliosis.

72. Special tests
 Thoracic and lumbar spine
 Straight leg raising test
 LASSEGUE’S SIGN
 Cross SLRT
 Reverse SLRT
 Femoral stretch test
 Bowstring test

73. STRAIGHT LEG RAISING TEST

74. STRAIGHT LEG RAISING TEST
 The patient lies supine on the examining table.
 First exclude that there is no compensatory lordosis by keep a
hand beneath the lumbar spine.
 The patient is now asked to raise one lower limb keeping knee
straight and continue to raise the leg till he experiences pain
as evidenced by watching his face.
 If the pain is evoked under 40 degrees it suggests
impingement of the protruding intervertebral disc on a nerve
root.
 If the pain is evoked at an angle above 40 degree
 It indicates tension on nerve root that is abnormally sensitive
from a cause not necessarily an intervertebral disc protrusion.

76. LASSEGUE’S SIGN
 At this angle when the patient experiences first twinge of
pain,the angle is pasively dorsiflexed.This causes
aggravation of the pain due to additional traction to the
sciatic nerve (LASSEGUE’S SIGN).
 This is imp to differentiate sciatica from diseases of
sacro-iliac joint.
 In sacro iliac joint diseases the SLRT is positive but there
will be no aggravation of pain during passive dorsiflexion
of the ankle

77. Cross SLRT

78. Reverse SLRT

79. Bowstring test

80. FEMORAL NERVE STRETCH TEST
 A patient with lumbar disc prolapse may complain of pain
in front of the thigh,this indicates that probably the
protruding disc is l2-l3 which is irritating the femoral
nerve.
 The patient is asked to lie on his abdomen and flex the
knee of the affected side, if this causes pain then its
confirmatory that L2-L3 lumbar disc is protruded to cause
stretching of the femoral nerve.

81. SACRO –ILIAC JOINT
 Inspection –the patient is stripped and examined in
standing ,sitting and recumbent positions.
 The position of the sacro iliac joint is determined by
presence of dimple situated just medial to the posterior
superior iliac spine.
 In standing postion the patient is asked to point out the
site of pain and direction in which it radiates.
 In recumbent position it should be noted whether the hip
and knee joints are slightly flexed or not

82. PALPATION
 Tenderness is elicited by placing the thumb over the
dimple and exerting pressure while the patient is asked to
bend forward.
 It may also be elicited by compressing the two iliac crests
together.

83. SPECIAL TESTS
 GENSLEN’S TEST-
 The hip and knee joints of
the affected side are
flexed to fix the pelvis and
the hip joint of the
unaffected side is
hyperextended over the
edge of the examining
table.
 This may exert a
rotational strain on the
sacro iliac joint and will
cause sharp pain.

84. GILLIES TEST
• The patient lies prone on the bed. The pelvis of the
patient is kept steadied by clinician’s hand on the
normal sacro iliac joint. The thigh of the affected side is
hyperextended passively with the other hand of the
clinician. A sharp pain is felt by the patient when the
sacro iliac joint is diseased

85. FABER Test
• The patient's tested leg is placed in a "figure-4" position
• knee is flexed and the ankle is placed on the opposite knee
• The hip is placed in Flexion, ABduction, and External Rotation (which is where the
name FABER comes from)
• posteriorly-directed force against the medial knee of the bent leg towards the
table top
• positive test occurs when groin pain or buttock pain is produced
• sacroiliac joint dysfunction

86. Compression distraction test
• Examiner crosses arms and places them at the medial aspects
of the patients ASIS's
• A gapping pressure is applied in an outward direction
bilaterally and simultaneously
• The examiner then uncrosses his/her arms and places his/her
hands on the iliac crests to apply an inward/downward force

87. • NEUROLOGICAL EXAMINATION

88. • Higher mental function
• Cranial nerves
• Motor function
• Sensory function
• Reflexes
• Visceral functions
• Involuntary movements
• Gait

89. Motor system
a. Bulk of muscle ( wasting or hypertrophy)
b. Tone of muscle
i. Hypertonia
1. Spasticity
2. Rigidity
ii. hypotonia
c. Power of muscle
d. Reflexes

90. Nerve root Test
C5 Elbow flexion
C6 Wrist extension
C7 Wrist flexion
C8 Finger flexion
T1 Finger abduction

91. • Upper limb
• C5 - lateral forearm
• C6 - lateral forearm
• - thumb and index finger
• C7 - middle finger
• C8 - ring and little fingers
• - medial forearm
• T1 - medial elbow
• - distal half of the medial arm
• T2 - proximal half of medial arm
Reflexes
Biceps (C5-6)
Brachioradialis
Triceps (C7-8)

92. • Reflexes
– Knee jerk (L3-4)
– Ankle jerk (S1-2)
– Babinski’s reflex
– Clonus
L1,2 Hip flexion
L3,4 Knee extension
L4 Dorsiflexion
L5 Great toe
extension
S1,2 Plantarflexion

93. Lower limb
L1 – groin
L2 – anterior thigh
L3 – anterior knee
L4 – medial aspect of
leg
L5 – lateral aspect of
leg
 - dorsal aspect of
foot
S1 – lateral aspect of foot
S2 – posterior aspect leg
and thigh
S3,S4,S5 – perianal region

94. • Sensory system
• a. Temperature
• i. Hot
• ii. cold
• b. Touch
• i. Deep
• ii. Crude
• iii. Light
• c. Posterior column sensations
• i. Two point discrimination
• ii. Vibration sense ( 128 Hz)
• iii. Position sense
• iv. stereognosis

95. • Co ordination mechanism
• a. Straight line walking
• b. Finger to nose & finger test
• c. Heel to knee test
• d. Romberg sign
• e. Pastpointing
• f. Dysdidokinesia

96. Gait