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THE PHYSICALTHE PHYSICAL

EXAMINATIONEXAMINATION

ofofTHE SPINETHE SPINE

Charles A Simanjuntak, dr, SpOT(K), MPdPSPD Universitas Jami

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!ntr"du#ti"n!ntr"du#ti"n

Careful Physical Examination is potentiallythe most valuable servicea physician canprovide to the patient. ( OKU Spine : !!" #

Complete exam :

Correct dia$nosis

%a$nitude of the problem

&etermine appropriate 'reatment

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!ntr"du#ti"n!ntr"du#ti"n

dvances in ima$in$ techni)ue %*+, C' etcPE -ess important

'ime consumin$

%*+, C' : hi$h false positive rate for spinaldisease*is/ : attributin$ asymptomatic lesion

0ail to identify actual problem source

1istory 2 PE &etermine nature 2 extent*adio$rafic study confirm &3

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O$%&$!%'O$%&$!%'

OOK4 inspection%%

4 palpation

MO$%4 active 2 passive

movements

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!*T&ODUCT!O*!*T&ODUCT!O*Smile, eye contact and sha/e hands

Explain in simple terms

Entire bac/ 2 le$s exposed

Patient standin$ upri$ht (initially#

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%+AM!*AT!O*%+AM!*AT!O*

Suitably undressed Usually do5n to under5ear Start 5ith the patient standin$

'hen lyin$ prone 0inally lyin$ supine

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%+AM!*AT!O*%+AM!*AT!O*

6eneral inspectionin front, beside 2 behind the patient,assess:

Posture

4 indicate normal curvatures of the spine7ony deformities

4 /yphosis, lordosis or scoliosis

4 spina8bifida

Pi$mentation, hair on sacral area

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eneral !nspe#ti"neneral !nspe#ti"n

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eneral !nspe#ti"neneral !nspe#ti"n

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eneral !nspe#ti"neneral !nspe#ti"n

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%+AM!*AT!O*%+AM!*AT!O*-- STA*D!*STA*D!*-oo/

9 Scars :previous sur$ery

9 -umps :abscess, tumour (e.$.sacral lipoma#, prominent

paravertebral muscle spasm9 Sinuses : deep infection

9 Caf au lait: spots 3 nodules:;eurofibromatosis

9 1airy patch:(spinal dysraphism#

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*

""k -9 ". hairlinedue to short nec/

Klippel80eil syndrome may beassociated 5ith Spren$el shoulder(undescended scapula#

9 D".n/s 0 M"r1ui" s2ndr"mes(tlanto8axial instability#

9 As2mmetr2 "3 sh"ulder hei4ht 0trunk alan#escoliosis (lateralcurvature 5ith rotational deformityof vertebral bodies#

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*""k -

-e$ len$th discrepancy ;erve *oot 'ension

(consistently stands 5ith one /neebent in spite of e)ual le$ len$ths, as

/nee flexion relieves the pull on thenerve roots#9 -ateral deviation of spine(

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*

""k -9 &"und a#kin4 0 hun#hed

sh"ulders:Schuermanns disease3/yphosis

9 ius (k2ph"s)-acute an$ular deformity 5ith bonyprominence, e.$. tuberculousvertebral collapse

9 Oserve 4ait

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%+AM!*AT!O* -%+AM!*AT!O* -STA*D!*STA*D!*

0eel :9 'enderness: may be bony,

intervertebral or paravertebral

9 7ony prominence or stepsspinous processes4 usin$ C? 23or -"8@4 as landmar/sfacet Aoints4 approx. cm lateral to spinous

processes

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*

0eel :assess ali$nment, mobility 2

tenderness of:4 transverse processes ofvertebrae

lateral to spinous processes

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*

%easurement:

step of si$n

Schober test

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%ovement:active movements:4 assess *O% of the spine4 describe:

5here movement ta/es place

5hat determines direction of movement 5hat structures limit this movement si$nificance of +B disc thic/ness

4 flexion sa$ittal arran$ement of facet Aoints

limited by li$aments 2 muscles

4 extension

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%+AM!*AT!O* - STA*D!*%+AM!*AT!O* - STA*D!*

%ovement :0lexion:Ensure spinal rather than hip flexion(by mar/in$ t5o spots about !cm apart on thepatient=s lumbar spine#

these should separate by a further @cmon flexionForward bend test:scoliosis disappears on for5ard bendin$ postural scoliosis disappears on sittin$,

le$ shortenin$ Scoliosis secondary tonerve root compression disappear afterresolution (spontaneous or sur$ical#, i.e.

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%+AM!*AT!O* -%+AM!*AT!O* -STA*D!*STA*D!*

%ovement :9 Extention4 'o arch bac/5ards

(be5are of bendin$ /nees#

4 'he

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- STA*D!*- STA*D!*%ovement :9 Extention

4 *otation

most rotation occurs in thethoracic spine, this should not bereduced in lumbo8sacral disease#

4 *ib ca$e excursionabout ?cm bet5een fullinspiration and full expiration#

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%+AM!*AT!O*%+AM!*AT!O*

C%&$!CA SP!*%0lexion:

%ost people can $et their chin on theirsuprasternal notch;o flexion in thoracic spine, because splinted by ribca$e

Extension:should allo5 nose or forehead to be parallel toceilin$

*otation:chee/ parallel to shoulder

*otation occurs mainly at atlantoaxial Aoint (C3C# ;o rotation in lumbar spine, because facet Aoints arevertical

-ateral flexion:very variable, and first movement to be restrictedin arthritis

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%+AM!*AT!O*%+AM!*AT!O*

S';&+;6 or S+''+;6Passive %ovement physically move patient throu$h full

ran$e of movement feel for resistance and

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%+AM!*AT!O*%+AM!*AT!O*

. -D+;6P*O;E-oo/ :

4 atch the patient climb on theexamination couch

0eel:4 0ocal spinal tenderness4 ssess sensation on bac/ of 5hole le$ if

5orried about cauda e)uina syndrome,perianal sensation may also be assessedhere

4 Chec/ popliteal and posterior tibial pulses

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%+AM!*AT!O*%+AM!*AT!O*

. -D+;6P*O;E %ovement :

4 0emoral nerve stretch

(Either acutely flex the /nee 5ith thethi$h restin$ on the couch, or extend thehip 5ith the /nee in moderate flexion# +f pain is elicited, there is a positive nervestretch test

4 ssess hip rotation and an/lereflexes5ith the /nee at F! de$rees offlexion

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%+AM!*AT!O*%+AM!*AT!O*. -D+;6SUP+;E

-oo/ :4 atch the patient turn over onto his3her bac/

0eel:4 Sensation can be tested here or at the end, in

the neurolo$ical examination4 *eflexes physiolo$icpatholo$ic

%ovement:4 ssess hip3/nee mobility

4 Strai$ht -e$ *aise (S-*sciatic nerve rootirritation(increased by dorsiflexion of the an/le#

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%+AM!*AT!O*%+AM!*AT!O*

. -D+;6SUP+;E%ovement :

4 ase4ue/s test -

4 5".strin4in4 test -ith hip flexed to F!o, extend the/nee as far as the patient tolerates.Pressure applied to the hamstrin$s

5ith the thumb 5ill immediatelycause pain if there is nerve rootirritation

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Si4ns "3 nerve r""tSi4ns "3 nerve r""t

#"mpressi"n#"mpressi"n

Standard full neurolo$ical examination ofboth lo5er limbs : tone, po5er (%*C $radin$# sensation (li$ht touch, pinpric/ 2

proprioceptive if indicated# reflexes (physiolo$ic and patolo$ic#

an anatomical distributionGdermatome(s# or myotome(s#H

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*eur"l"4i#al %6aminati"n*eur"l"4i#al %6aminati"n

ObAectives :4 &etermine if defect is present

4 -ocaliIe the level of the deficit+nclude :

4 Sensory

4 %otor

4 *eflex

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*eur"l"4i#al %6aminati"n*eur"l"4i#al %6aminati"n

Sensory examinationExplain, eyes closedExamine : touch, point discrimination,

proprioceptive.Sensory dermatomes, compare each

opposite

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Sens"r2 Dermat"meSens"r2 Dermat"me

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Mus#le P".er radin4Mus#le P".er radin4

! 8 complete paralysis 8 flic/er of contraction possible 8 movement is possible 5hen $ravity is

excludedJ 8 movement is possible a$ainst $ravity" 8 movement is possible a$ainst $ravity

some resistance@ 8 normal po5er

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*eur"l"4i#al %6aminati"n*eur"l"4i#al %6aminati"n

%otorexamination

%uscle $radin$

Compare each sideCervical :Scapular C4

Deltoid & Bicep C!"rit e#te$io$ & upi$atio$ C%

"rit fle#io$ & Pro$atio$ C

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*eur"l"4i#al %6aminati"n*eur"l"4i#al %6aminati"n

M"t"re6aminati"n

-umbo8sacral

Hip fle#orHip e#te$or

L '()(*S'

+$ee fle#or+$ee e#te$or

L 4(!( S'()L )(*(4

A$,le fle#orA$,le e#te$or S'L!

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&e3le6es&e3le6esBiceps Triceps

Brachioradialis Hoffman

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&e3le6es&e3le6esKnee Patellar Achilles

Babinsky

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SL- / itti$0

& upi$e

Must produce radicular symptom in thedistribution of the provoked root, for

sciatic nerve , that means pain distalto knee

SL- / itti$0

& upi$eSL radiculopathy a!!ravated by ankle

dorsofle"ion

Co$tralateral

SL-

#ell$le! SL puts tension on involved root

from opposite direction

+er$i01

te

The neck is fle"ed chin to chest% The hip isfle"ed to &'(, and then the le! is the

e"tended similar to SL) radiculopathy is

P-O.OCATI.E TESTS

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P-O.OCATI.E TESTS

TEST COMMENTS

Bo2tri$0 i0$

SL radiculopathy a!!ravated by applyin!pressure over popliteal fossa%

3eoral tretc5tet

Prone patient) e"aminer stretch femoral nerveroots to test L*$L+ irritation

Naf6i0er1 tet

ompression of neck vein for -' s .ith patientlyin! supine )

cou!hin! then reproduces radiculopathy

Mil0ra1 tet

Patient raises both le!s off the e"aminin! tableand hold this

position for /' s) radiculopathy maybe

d d