PHYSICAL EXAMINATION OF THE SPINE

PHYSICAL PHYSICAL EXAMINATION OF THE EXAMINATION OF THE

SPINESPINE

Prof. Dr. Şafak Sahir Prof. Dr. Şafak Sahir KARAMEHMETOĞLU, MD.KARAMEHMETOĞLU, MD.

İU/CMF/PMRDİU/CMF/PMRD

CERVICAL SPINECERVICAL SPINE

INSPECTION-1INSPECTION-1

- Lordosis- Lordosis - Scoliosis- Scoliosis - Swelling- Swelling - Torticollis- Torticollis - Muscle atrophy- Muscle atrophy

INSPECTION-2INSPECTION-2

- Muscle hypertrophy- Muscle hypertrophy

- Color changes- Color changes

- Arterial pulse- Arterial pulse

- Postural changes- Postural changes

PALPATION-1PALPATION-1

* Bone-Joint* Bone-Joint

- Spinous process- Spinous process

- Interspinous space - Interspinous space

- Foramen- Foramen


* SOFT TISSUES* SOFT TISSUES

- Swelling - Swelling

- PVM- PVM

- SCMM- SCMM

- Spinal nerves- Spinal nerves

- Ligaments- Ligaments


* * Neighbouring structuresNeighbouring structures

- Arterial pulse- Arterial pulse

- Lymph nodules- Lymph nodules

- Thyroid- Thyroid

- Trachea- Trachea

- Others- Others

ROMROM - Flexion- Flexion - Extension- Extension - Lateral Flexion (45- Lateral Flexion (45°°)) - Rotations- Rotations

- Translations- Translations- Circumflexion - Circumflexion

NEUROLOGIC EXAMINATIONNEUROLOGIC EXAMINATION

- Cervical Plexus- Cervical Plexus C1-C4C1-C4

- Brachial Plexus- Brachial Plexus C5-T1C5-T1

Cervical PlexusCervical Plexus

Has no key muscle, flexors, extensors, Has no key muscle, flexors, extensors, lateral flexors and rotators are tested in groups.lateral flexors and rotators are tested in groups.

C1: Mainly motor fibres.C1: Mainly motor fibres.C2: Key point: protuberantia occipitalis externa.C2: Key point: protuberantia occipitalis externa.C3: Key point: middle of the fossa supraclavicularis.C3: Key point: middle of the fossa supraclavicularis.C4: Key point: acromio-clavicular joint.C4: Key point: acromio-clavicular joint.

Brachial PlexusBrachial Plexus

C5: KM: biceps, brachialis, KP: lateral of the antecubital fossa, DTR: C5: KM: biceps, brachialis, KP: lateral of the antecubital fossa, DTR: biceps.biceps.C6: KM: extensor carpi radialis longus and brevis, KP: middle of the C6: KM: extensor carpi radialis longus and brevis, KP: middle of the dorsum of the first phalanx of the thumb, DTR: brachioradialis.dorsum of the first phalanx of the thumb, DTR: brachioradialis.C7: KM: triceps, KP: middle of the dorsum of the first phalanx of the C7: KM: triceps, KP: middle of the dorsum of the first phalanx of the middle finger, DTR: tricepsmiddle finger, DTR: tricepsC8: KM: flexor digitorum profundus, KP: middle of the dorsum of the C8: KM: flexor digitorum profundus, KP: middle of the dorsum of the first phalanx of the little finger. first phalanx of the little finger. T1:T1: KMKM:: abductor digiti minimi, KP: medial of the antecubital abductor digiti minimi, KP: medial of the antecubital fossa.fossa.

Special Tests -1-Special Tests -1-

Distraction: To perform this test, place the open palm of one Distraction: To perform this test, place the open palm of one hand under the patient’s chin, and the other hand under the hand under the patient’s chin, and the other hand under the occiput. Then, gradually lift (distract) to remove its weight occiput. Then, gradually lift (distract) to remove its weight from the neck, if the neck and/or arm pain decreases or from the neck, if the neck and/or arm pain decreases or disappaers, the test is positive.disappaers, the test is positive.

It demonstrates the effect that neck traction might have in It demonstrates the effect that neck traction might have in relieving pain by widening the foramen, decreasing pressure relieving pain by widening the foramen, decreasing pressure on the joints capsules around the facet joints. In addition it on the joints capsules around the facet joints. In addition it may help to alleviate muscle spasm by relaxing the may help to alleviate muscle spasm by relaxing the contracted muscles. contracted muscles.


Compression: To perform this test, press down upon the top of Compression: To perform this test, press down upon the top of the patient’s head while he is either sitting or lying down, if the patient’s head while he is either sitting or lying down, if there is an increase in pain in the neck and/or arm(s), then there is an increase in pain in the neck and/or arm(s), then the test is considered to be positive. the test is considered to be positive.

A narrowing of the neural foramen, pressure on the facet joints A narrowing of the neural foramen, pressure on the facet joints or muscle spasm can cause increased pain. In addition, this or muscle spasm can cause increased pain. In addition, this test may reproduce pain referred to the upper extremity test may reproduce pain referred to the upper extremity from the cervical helping to locate the neurological level of from the cervical helping to locate the neurological level of any existing pathology.any existing pathology.


Valsalva: To perform this test, have the patient hold his breath Valsalva: To perform this test, have the patient hold his breath and bear down as he/she were moving his/her bowels. Then, and bear down as he/she were moving his/her bowels. Then, ask the patient whether he/she feels any increase in pain, ask the patient whether he/she feels any increase in pain, and if so, whether he/she can describes the location. If the and if so, whether he/she can describes the location. If the response is accurate, the test is positive. response is accurate, the test is positive.

This test increases intrathecal pressure. If a space occupying This test increases intrathecal pressure. If a space occupying lesion such as a herniated disc or a tumor, is present in the lesion such as a herniated disc or a tumor, is present in the cervical canal, the patient may develop pain in the cervical cervical canal, the patient may develop pain in the cervical spine. The pain may also radiate according to the spine. The pain may also radiate according to the neurological level.neurological level.


Swallowing: Difficulty or pain upon swallowing Swallowing: Difficulty or pain upon swallowing can sometimes be caused by cervical spine can sometimes be caused by cervical spine pathology such as bony protuberances, pathology such as bony protuberances, osteophytes, or by soft tissue swelling due to osteophytes, or by soft tissue swelling due to hematomas, infection, or tumor in the anterior hematomas, infection, or tumor in the anterior portion of the cervical spine.portion of the cervical spine.


Adson: To perform this test, take the patient’s radial pulse at Adson: To perform this test, take the patient’s radial pulse at the wrist. As you continue to feel the pulse, abduct, extend the wrist. As you continue to feel the pulse, abduct, extend and externally rotate his arm. Then istruct him/her to take a and externally rotate his arm. Then istruct him/her to take a deep breath and to turn his/her head toward the arm being deep breath and to turn his/her head toward the arm being tested. If there is compression of the subclavian artrey, you tested. If there is compression of the subclavian artrey, you will feel a marked diminution or absence of the radial pulse, will feel a marked diminution or absence of the radial pulse, then the test is positive. then the test is positive.

This test is used to determine the state of the subclavian artery, This test is used to determine the state of the subclavian artery, which may be compressed by an extra cervical rib or by which may be compressed by an extra cervical rib or by tightened scalenus anticus and scalenus medius muscles, tightened scalenus anticus and scalenus medius muscles, which can compress the artery where it passes between which can compress the artery where it passes between them on its way to the upper extremity.them on its way to the upper extremity.


Spurling: To perform this test, instruct the paient to extend, Spurling: To perform this test, instruct the paient to extend, lateral flex and rotate his/her head. Then, press down upon lateral flex and rotate his/her head. Then, press down upon the the top of the patient’s head while he is either sitting or the the top of the patient’s head while he is either sitting or lying down, if there is an increase in pain in the neck and/or lying down, if there is an increase in pain in the neck and/or arm(s), then the test is considered to be positive. arm(s), then the test is considered to be positive.

A narrowing of the neural foramen, pressure on the facet joints A narrowing of the neural foramen, pressure on the facet joints or muscle spasm can cause increased pain. In addition, this or muscle spasm can cause increased pain. In addition, this test may reproduce pain referred to the upper extremity test may reproduce pain referred to the upper extremity from the cervical helping to locate the neurological level of from the cervical helping to locate the neurological level of any existing pathology.any existing pathology.

Special Tests -7-Special Tests -7-Slump: Slump: This test is a progressive series of maneuvers This test is a progressive series of maneuvers

designed to place the sciatic nerve roots under designed to place the sciatic nerve roots under increasing tension. Tincreasing tension. The patient sitting on the he patient sitting on the examining table, flexes the cervical, thoracic and examining table, flexes the cervical, thoracic and lumbar spine, extends one of the knees and lumbar spine, extends one of the knees and dorsifelexes the foot on the same side. If the patient dorsifelexes the foot on the same side. If the patient experiences pain in low-back and/or leg(s), the test experiences pain in low-back and/or leg(s), the test is positive.is positive.

THORACAL SPINE

INSPECTION-1

* The patient must be undressed,* Posture* Supine, prone and side-lying

INSPECTION-2

* Spina scapula T3 * End of scapula T7-9* Medial border of the scapula and spinous processes 5 sm.* End of the ears, acromions and, iliac crests must be horizontal

PALPATION and PRESSION

* PVM* Facet joints* Spinous processes* Interspinous spaces

ROM-1

* Flexion 20-45°* Extension 20-45°* Lateral flexion 20-40°* Rotation 35-50°

ROM-2

* Sitting position,* C7-T12: 3 sm., C7-S1 15 sm.* Structural scoliosis does not

change in flexion

The level of the lesion by key points There is no key muscle Beevor’s sign

Neurologic ExaminationNeurologic Examination

Key PointsKey Points

T2: KP: Apex of the axillaT2: KP: Apex of the axillaT3: KP: Third intercostal space (mid-clavicular line)T3: KP: Third intercostal space (mid-clavicular line)T4: KP: Fourth intercostal space (nipple level, mid-clavicular line)T4: KP: Fourth intercostal space (nipple level, mid-clavicular line)T5: KP: Fifth intercostal space (mid-clavicular line) T5: KP: Fifth intercostal space (mid-clavicular line) T6: KP: Sixth intercostal space (xiphoid level, mid-clavicular line) T6: KP: Sixth intercostal space (xiphoid level, mid-clavicular line) T7: KP: Between T6 and T8 (mid-clavicular line) T7: KP: Between T6 and T8 (mid-clavicular line) T8: KP: Between T7 and T9 (mid-clavicular line) T8: KP: Between T7 and T9 (mid-clavicular line) T9: KP: Between T8 and T10 (mid-clavicular line) T9: KP: Between T8 and T10 (mid-clavicular line) T10: KP: Umblicus (mid-clavicular line) T10: KP: Umblicus (mid-clavicular line) T11: KP: Between T10 and T12 (mid-clavicular line) T11: KP: Between T10 and T12 (mid-clavicular line) T12: KP: Superior of the middle of the inguinal ligament (mid-clavicular T12: KP: Superior of the middle of the inguinal ligament (mid-clavicular

line) line)

Special tests

* Slump * Passive scapular approximation* First thoracal nerve stretching

Special tests - 2Special tests - 2

Passive scapular approximation test: The Passive scapular approximation test: The patient lies prone. The shoulders are patient lies prone. The shoulders are stretched backwards with the stretched backwards with the approximation of scapulae. If there is approximation of scapulae. If there is pain or pain worsening the test is pain or pain worsening the test is pozitive.pozitive.

This test stretches the first thoracal spinal This test stretches the first thoracal spinal nerve.nerve.


First thoracal nerve stretching test: The First thoracal nerve stretching test: The patient abducts the shoulder to 90patient abducts the shoulder to 90°°, flexes , flexes the elbow and holds the occipital region the elbow and holds the occipital region of the head and the shoulder is forced to of the head and the shoulder is forced to extention. If there is pain or pain extention. If there is pain or pain worsening the test is pozitive.worsening the test is pozitive.

This test stretches the first thoracal spinal This test stretches the first thoracal spinal nerve.nerve.


Beevor's signBeevor's sign is the movement of the belly is the movement of the belly button towards the head on flexing the neck. button towards the head on flexing the neck. It is caused by weakness of the lower It is caused by weakness of the lower abdominal muscles.abdominal muscles.

Beevor’s sign is characteristic of Beevor’s sign is characteristic of spinal cord injury at the T10 level. It has also been injury at the T10 level. It has also been described in described in amyotrophic lateral sclerosis and and facioscapulohumeral muscular dystrophy..

LUMBAR SPINE

INSPECTION - 1INSPECTION - 1

- Lordosis - Scoliosis - Swelling - Deviation - Muscle atrophy

INSPECTION - 2INSPECTION - 2

- Muscle spasm- Muscle spasm

- Color changes- Color changes

- Lipomas- Lipomas

- Abnormal hair- Abnormal hair

- Café au lait spots- Café au lait spots

- Postural changes- Postural changes

PALPATION-1

Bone – Joint: - Spinous processes - Interspinous spaces - Facet joints

- İliac crests- Coccyx

PALPATION-2

SOFT TISSUESSOFT TISSUES

- Swelling- Swelling

- PVM- PVM

- Ligaments- Ligaments

- Umblicus (L3-4)- Umblicus (L3-4)

- Sacral promontorium- Sacral promontorium

PALPATION-3

VALLEIX POINTS:VALLEIX POINTS:

1. Middle of the trochanter major ve ischial 1. Middle of the trochanter major ve ischial tuberositytuberosity

2. Middle of the posteroir thigh2. Middle of the posteroir thigh

3. Middle of the popliteal fossa3. Middle of the popliteal fossa

4. Middle of the gastrocnemius muscle4. Middle of the gastrocnemius muscle

5. Middle of the Achilles tendon5. Middle of the Achilles tendon

ROMROM

- Flexion- Flexion

- Extension- Extension

- Lateral Flexion - Lateral Flexion

- Rotations- Rotations

- Circumduction- Circumduction

- DTRDTR- Muscle testing- Muscle testing- Sensation- Sensation

NEUROLOGIC EXAMINATION

L1: KM: None, KP: inferior of the middle of the inguinal ligament.L1: KM: None, KP: inferior of the middle of the inguinal ligament.L2: KM: iliopsoas, KP: midway of the KPs L1 and L3 L2: KM: iliopsoas, KP: midway of the KPs L1 and L3 L3: KM: quad. femoris, KP: medial femoral condyl, DTR: patella.L3: KM: quad. femoris, KP: medial femoral condyl, DTR: patella.L4: KM: tibialis anterior, KP: medial malleolusL4: KM: tibialis anterior, KP: medial malleolusL5: KM: extensor hallucis longus, KP: third metatarsophalangeal L5: KM: extensor hallucis longus, KP: third metatarsophalangeal joint at the dorsum of the foot. joint at the dorsum of the foot. S1: KM: gastrocnemius-soleus, KP: lateral of the heel, DTR: S1: KM: gastrocnemius-soleus, KP: lateral of the heel, DTR: Achilles. Achilles.

Neurologic examination

Straight Leg Raising Test (SLRT): The patient lies on his Straight Leg Raising Test (SLRT): The patient lies on his back (supine). The examiner raises the leg with the knee back (supine). The examiner raises the leg with the knee extended straight. Normally, the angle between the leg and extended straight. Normally, the angle between the leg and the bench can reach 70the bench can reach 70°° – 80 – 80°° without any discomfort. If the without any discomfort. If the patient experiences pain before, the test is positive.patient experiences pain before, the test is positive.

To differentiate between sciatic nerve stretching and To differentiate between sciatic nerve stretching and hamstring muscles tightness, lower the leg a few angle and hamstring muscles tightness, lower the leg a few angle and dorsiflex the foot in order to relax the hamstrings and to dorsiflex the foot in order to relax the hamstrings and to stretch sciatic nerve. If the patient reexperiences pain along stretch sciatic nerve. If the patient reexperiences pain along the sciatic nerve, this is due to sciatic nerve stretching. the sciatic nerve, this is due to sciatic nerve stretching.

Special tests – 1- Special tests – 1-

Contralateral SLRT: If there is low-back and/or Contralateral SLRT: If there is low-back and/or contralateral leg pain when the uninvolved leg is contralateral leg pain when the uninvolved leg is raised the test is positive.raised the test is positive.

This test may be associated with a considerable disc This test may be associated with a considerable disc hernation or a space occupying lesion. hernation or a space occupying lesion.


Kernig’ sign: The patient lies supine (flat on the Kernig’ sign: The patient lies supine (flat on the back), flexes his head with hands on the occipital back), flexes his head with hands on the occipital region. If the patient experiences neck pain and/or region. If the patient experiences neck pain and/or pain along the vertebral column the test is positive. pain along the vertebral column the test is positive.

This may be a sign of meningeal or spinal nerve roots This may be a sign of meningeal or spinal nerve roots irritation.irritation.


Naffziger’s test: Pressure is applied on the jugular vein Naffziger’s test: Pressure is applied on the jugular vein of the patient lying on his/her back for 10 seconds. of the patient lying on his/her back for 10 seconds. When the face of the paient flushes he/she is requested When the face of the paient flushes he/she is requested to cough. If he/she experiences low-back and/or leg to cough. If he/she experiences low-back and/or leg pain the test is positive. pain the test is positive.

Pressure on the jugular vein results in increased Pressure on the jugular vein results in increased cerebrospinal fluid pressure and may cause pain in the cerebrospinal fluid pressure and may cause pain in the case of a herniated disc.case of a herniated disc.


Valsalva test: The patient takes a deep breath, holds Valsalva test: The patient takes a deep breath, holds and attempts exhalation against a closed and attempts exhalation against a closed glottis and and closed mouth and nose. closed mouth and nose. If there is low-back and/or leg pain the test is If there is low-back and/or leg pain the test is positive. positive. Valsalva test increases the intrathecal pressure.Valsalva test increases the intrathecal pressure.



Hoover test: THoover test: This test determines whether the patient is his test determines whether the patient is malingering when he states that he/she cannot raise his leg, malingering when he states that he/she cannot raise his leg, and should be performed in conjuction with straight leg and should be performed in conjuction with straight leg raising test. When a patient is genuinely trying to raise raising test. When a patient is genuinely trying to raise his/her leg, he/she puts pressure on the calcaneus of his/her his/her leg, he/she puts pressure on the calcaneus of his/her opposite leg to gain leverage; you can feel downwardopposite leg to gain leverage; you can feel downwardpressure on your hand. If there is no pressure the patient is pressure on your hand. If there is no pressure the patient is malingering.malingering.

Special Tests - 7Special Tests - 7

Pelvic Rock: Pelvic Rock: The patient lying supine, the The patient lying supine, the examiner places hands on the iliac crests of examiner places hands on the iliac crests of the patient with thumbs on the anterior the patient with thumbs on the anterior superior iliac spines, and palms on the iliac superior iliac spines, and palms on the iliac tubercles. Then, forcibly compresses the tubercles. Then, forcibly compresses the pelvis toward the midline of the bodypelvis toward the midline of the body. If the . If the patient complains of pain around the patient complains of pain around the sacroiliac joint, there may be pathology in the sacroiliac joint, there may be pathology in the joint itself, such an infection or problem joint itself, such an infection or problem secondary to trauma. secondary to trauma.


Gaenslen’s sign: Gaenslen’s sign: Have the patient lie supine on Have the patient lie supine on the table and ask him to draw both legs onto the table and ask him to draw both legs onto the chest. Then, shift the patient to the side of the chest. Then, shift the patient to the side of the table so that one buttock extends over the the table so that one buttock extends over the edge of the table while the other remains on it. edge of the table while the other remains on it. Allow the unsupported leg to drop over the Allow the unsupported leg to drop over the edge, while the opposite leg remains flexed. edge, while the opposite leg remains flexed. Complaints of subsequent pain in the area of Complaints of subsequent pain in the area of the sacroiliac joint give another indication of the sacroiliac joint give another indication of pathology in that area.pathology in that area.


Femoral nerve stretch: Femoral nerve stretch: The patient The patient lying prone, the examiner fully lying prone, the examiner fully flexes the knee and extends the hip. flexes the knee and extends the hip. If the patient experiences pain in If the patient experiences pain in the anterior area of the thigh, the the anterior area of the thigh, the test is positive. test is positive.


Slump: Slump: This test is a progressive series of This test is a progressive series of maneuvers designed to place the sciatic nerve maneuvers designed to place the sciatic nerve roots under increasing tension. Troots under increasing tension. The patient he patient sitting on the examining table, flexes the sitting on the examining table, flexes the cervical, thoracic and lumbar spine, extends cervical, thoracic and lumbar spine, extends one of the knees and dorsiflexes the foot on the one of the knees and dorsiflexes the foot on the same side. If the patient experiences pain in same side. If the patient experiences pain in low-back and/or leg(s), the test is positive.low-back and/or leg(s), the test is positive.

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PHYSICAL EXAMINATION OF THE SPINE

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