Spine Examination

Mario Johan Heryputra

11.2012.208
Clinical assessment
Symptom
Usual symptom of back disorder:
Pain,
stiffness,
deformity,
paraesthesia or the weakness in the lower limbs.

Mode of onset: start suddenly, after lifting strain, or
gradually without any antecendent event.

Pain
Sharp and localised / chronic and diffuse?
Which site and side?
Extending?
Worse by rest / by activity ?
Pain arising from facet
joints
Probably comes from any
of the soft tissue support
of the spine
Stiffness
Sudden in onset and almost complete (in a
locked back attack, or after a disc prolapse)

Continous and predictably worse in the morning
(suggesting arthritis or ankylosing spondylitis)
Deformity
Usually noticed by others, but the patient may
become aware of shoulder asymmetry or of
clothes not fitting well
Numbness or paraesthesia
Felt anywhere in the lower limb, but can
ussually be mapped fairly accurately over one
of the dermatomes.
It is important to ask if it is aggravated by
standing or walking and relieved by sitting
down the classic symptom of spinal stenosis
Other sypmtoms
Urinary retention or incontinence can be due to pressure on
the cauda equina

Faecal incontinence or urgency, and impotence may also
occur

Other sypmtoms important in back disorder are (1) urethral
discharge; (2) diarrhoea; (3) sore eyes classical features of
Reiters disease.
Sign with the patient standing
Look
Start by examining the skin :
Scars (previous surgery or injury)
Pigmentation (neurofibromatosis?)
Or abnormal tufts of hair (spina bifida?)

Look carefully at the patients shape and posture, both from the front
and behind. Asymetry of the chest, trunk or pelvis may be obvious, or
may appear only when the patient bends forward.

Lateral deviation of the spinal column is describes as a list to one or
other side, lateral curvature is scoliosis


Seen from the side, the back normally has a slight forward curve, or
kyphosis, in the thoracic region and a shorter backward curve, or
lordosis, in the lumbar segment.

Excessive thoracic kyphosis is sometimes called hyperkyphosis to
distinguish it from the normal, if the spine is sharply angulated the
prominence is called a kyphos or gibbus.

The lumbar spine may be excessively lordosed (hyperlordosis) or
unusually flat (effectively a lumbar kyphosis)

Undue or asymetrically prominence of the paravertebral muscles may
be due to spasm, an important sign in acute back disorder.
18.1 Examination With the patient standing upright (a), look at his general posture and
note particularly the presence of any asymmetry or frank deformity of the spine. Then
ask him to lean backwards (extension) (b), forwards to touch his toes (flexion) (c) and
then sideways as far as possible (d), comparing his level of reach on the two sides.
Finally, hold the pelvis stable and ask the patient to twist first to one side and then to the
other (rotation). Note that rotation occurs almost entirely in the thoracic spine (e) and
not in the lumbar spine.
(a) (c) (b) (e) (d)
Feel
Feel for the spinous processes and interspinous ligaments,
noting any unusual prominence or a step.

Tenderness should be localized to:
(1) bony structures; (2) intervertebral tissues; (3)
paravertebral muscles and ligaments, especially where
they insert into the iliac crest.




Move

Flexion is tested by asking the patient to try to touch his toes.
Even with a stiff back he may be able to do this by flexing the hips; so
watch the lumbar spine tosee if it really moves, or, better still, measure
the spinal excursion. The mode of flexion (whether it is smooth or
hesitant) and the way in which the patient comes back to the upright
position are also important. In clinical lumbar instability the patient
tends to regain the upright position by pushing on the front of his
thighs.

To test extension, ask the patient to lean backwards, but see that he
doesnt cheat by bending his knees. A patient with good forward
bending but much pain on extension probably has painful facet joints.

The wall test will unmask a minor flexion deformity (kyphosis, as in
ankylosing spondylitis or Scheuermanns osteochondrosis); standing
with the back flush against a wall, the heels, buttocks, shoulders and
occiput should all make contact with the vertical surface.

18.2 Measuring the range of flexion Bending down and touching the toes may look
like lumbar flexion but this is not always the case. The patient in (a) has anklyosing
spondylitis and a rigid lumbar spine, but he is able to reach his toes because he has
good flexibility at the hips. Compare his flat back with the rounded back of the
model in Figure 18.1c. You can measure the lumbar excursion. With the patient
upright, select two bony points 10 cm apart and mark the skin (b); as the patient
bends forward, the two points should separate by at least a further 5 cm (c).
(a) (b) (c )
Lateral flexion is tested by asking the patient to bend sideways,
sliding his hand down the outer side of his leg; the two sides are
compared. Rotation is examined by asking him to twist the trunk to
each side in turn while the pelvis is anchored by the examiners
hands; this is essentially a thoracic movement and is not limited in
lumbosacral disease.

Rib-cage excursion is assessed by measuring the chest
circumference in full expiration and then in full inspiration; the
normal difference is about 7 cm. A reduced excursion may be the
earliest sign of ankylosing spondylitis.

While the patient is standing, you can test muscle power in the
legs by asking him to stand up on his toes (plantarflexion) and then
to rock back on his heels (dorsiflexion); small differences between
the two sides are easily spotted.
SIGNS WITH THE PATIENT LYING PRONE
Make sure that the patient is lying comfortably on the examination
couch, and remove the pillow so that he is not forced to arch his back (or
smother himself). Again, look for localized deformities and muscle spasm,
and examine the buttocks for gluteal wasting. Feel the bony outlines (is
there an unexpected step or prominence?) and check for consistently
localized lumbosacral tenderness or soft-tissue trigger points. The
popliteal and posterior tibial pulses are felt, hamstring power is tested and
sensation on the back of the limbs assessed.

The femoral nerve stretch test (for lumbar 3
rd
or 4
th
nerve root
sensitivity) is carried out by gently flexing the patients knee or by lifting
the hip into extension (or both in one movement); pain may be felt in the
front of the thigh.
18.3 Examination with the patient prone (a) Feel for tenderness, watching the
patients face for any reaction. (b) Performing the femoral stretch test. You can
test for lumbar root sensitivity either by hyperextending the hip or by acutely
flexing the knee with the patient lying prone. Note the point at which the
patient feels pain and compare the two sides. (c) While the patient is lying
prone, take the opportunity to feel the pulses. The popliteal pulse is easily felt
if the tissues at the back of the knee are relaxed by slightly flexing the knee.
(a) (b) (c)
SIGNS WITH THE PATIENT LYING SUPINE
The patient is observed as he turns is there pain or
stiffness? A rapid appraisal of the thyroid, chest (and
breasts), and abdomen (and scrotum) is advisable, and
essential if there is even a hint of generalized disease. Hip
and knee mobility are assessed before testing for spinal
cord or root involvement.
The straight-leg raising test discloses lumbosacral root tension. Ask
the patient to hold his or her knee absolutely straight, then lift the
patients leg slowly until he or she experiences pain not merely in the
lower back (which is common and not significant) but also in the buttock,
thigh and calf (Lasegues test, but attribution is controversial); the angle at
which this occurs is noted.

Normally it should be possible to raise the limb to 8090 degrees;
people with lax ligaments can go even further. In a full-blown disc prolapse
with nerve root compression, straight-leg raising may be restricted to less
than 30 degrees because of severe pain in the sciatic distribution, not back
pain.

At the point where the patient experiences discomfort, passive
dorsoflexion of the foot may cause an additional stab of sciatic pain. A
gentler (and some would say more meaningful) way of testing straight-leg
raising is to ask the patient to raise the leg with the knee straight and rigid
and to stop when he or she feels pain.

The bowstring sign is even more specific. Raise the patients leg
gently to the point where he or she experiences sciatic pain; now, without
reducing the amount of lift, bend the knee so as to relax the sciatic nerve.
Buttock pain is immediately relieved; pain may then be re-induced
without extending the knee by simply pressing on the lateral popliteal
nerve behind the lateral tibial condyle, to tighten it like a bowstring.

Sometimes straight-leg raising on the unaffected side produces pain
on the affected side. This crossed sciatic tension is indicative of severe root
compression, usually due to a large central disc prolapse, and warns of the
risk to the sacral nerve roots that control bladder function (the cauda
equina syndrome one of very few surgical emergencies in spinal
disorders).
A full neurological examination of the lower limbs is then carried out.
An absent ankle jerk on the side of sciatica, combined with paraesthesiae
along the lateral border of the foot, suggests compression of the S1 nerve
root; normal reflexes combined with paraesthesiae on the dorsum of the
foot, suggests compression of the L5 nerve root. Check for clonus and a
positive Babinski sign; if present there should be some alarm regarding
possible spinal cord compression.

Ankle clonus with a positive Babinski sign suggests brain or spinal
cord pathology until proved otherwise.

The lower limbs should be carefully examined for length discrepancy
and trophic changes; the pulses are felt in the groin, the popliteal fossa
and around the ankle.

Unless the signs point unequivocally to a spinal disorder, rectal and
vaginal examination may also be necessary.
18.4 Sciatic stretch tests
(a) Straight-leg raising. The
knee is kept absolutely
straight while the leg is
slowly lifted (or raised by the
patient himself); note where
the patient complains of
tightness and pain in the
buttock this normally
occurs around 80 or 90.
(b) At that point a more
acute stretch can be applied
by passively dorsoflexing the
foot this may cause an
added stab of pain. (c) The
bowstring sign is a
confirmatory test for sciatic
tension. At the point where
the patient experiences pain,
relax the tension by bending
the knee slightly; the pain
should disappear. Then apply
firm pressure behind the
lateral hamstrings to tighten
the common peroneal nerve
(d); the pain recurs with
renewed intensity.
(a) (b)
(c)
(d)
IMAGING
Plain x-rays

Begin with anteroposterior and lateral views of
the spine; for the lumbar region, oblique views
of the spine, an anteroposterior x-ray of the
pelvis and a postero- anterior view of the
sacroiliac joints may also be needed.
In the anteroposterior view the spine should look perfectly
straight and the soft-tissue shadows should outline the
normal muscle planes. Curvature (scoliosis) is obvious, and
best shown in erect views. Bulging of the psoas muscle or
loss of the psoas shadow may indicate a paravertebral
abscess. Individual vertebrae may show alterations in
structure, e.g. asymmetry or collapse. Check the outlines of
the pedicles, which normally look like oval footprints near
the lateral edges of each rectangular vertebral body: a
missing or misshapen pedicle could be due to erosion by
infection, a neurofibroma or metastatic disease.
In the lateral view the normal thoracic kyphosis (up to 40 degrees) and
lumbar lordosis should be regular and uninterrupted. Anterior shift of an
upper segment upon a lower (spondylolisthesis) may be associated with
defects of the posterior arch, which show best in oblique views.
Vertebral bodies, which should be rectangular, may be wedged or
biconcave, deformities typical of osteoporosis or old injury. Bone density
and trabecular markings also are best seen in lateral films. Lateral views
in flexion and extension may reveal excessive intervertebral movement,
a possible cause of
back pain.
The intervertebral spaces may be edged by bony
spurs (suggesting longstanding disc degeneration) or
bridged by fine bony syndesmophytes (a cardinal feature
of ankylosing spondylitis).

The sacroiliac joints may show erosion or ankylosis, as in
tuberculosis (TB) or ankylosing spondylitis, and the hip joints
may show arthrosis, not to be missed in the older patient
with backache.
Intervertebral disc
Facet joint
Pedicle
Spinous process
Scalloping (erosion) of
vertebral bodies
Vertebral body
Intervertebral disc
Facet joint
18.5 Lumbar spine x-rays (a,b) The most important normal features are
demonstrated in the lower lumbar spine. In this particular case there are also
signs of marked posterior vertebral body and facet joint erosions at L1 and L2,
features that are strongly suggestive of an expanding neurofibroma.
Radioisotope scanning
Isotope scans may pick up areas of increased activity,
suggesting a fracture, a local inflammatory lesion or a
silent metastasis.
Computed tomography
Computed tomography (CT) is helpful in the diagnosis
of structural bone changes (e.g. vertebral fracture)
and intervertebral disc prolapse. When combined with
myelography it gives valuable information about the
contents of the spinal canal.
Discography and facet joint arthrography
These are sometimes performed in the investigation
of chronic back pain. Remember, though, that disc
degeneration and facet joint arthritis are common in
older people and are not necessarily the cause of the
patients symptoms. These are painful investigations,
no longer easily justified where MRI is available.
Magnetic resonance imaging
MRI has virtually done away with the need for myelography, discography,
facet arthrography, and much of CT scanning. The spinal canal and disc
spaces are clearly outlined in various planes. Scans can reveal the
physiological state of the disc as regards dehydration, as well as the effect
of disc degeneration on bone marrow in adjacent vertebral bodies.
L2
L5
L3
L4
18.6 MRI and discography (a) The lateral T2-weighted MRI shows a small posterior disc
bulge at L4/5 and a larger protrusion at L5/S1. (b) The axial MRI shows the disc
prolapse encroaching on the intervertebral canal and the nerve root on the left side.
(c) Discography, showing normal appearance at the upper level and a degenerate disc
with prolapse at the level below.
(a) (b) (c)
Solomon L, Warmick D, Nayagam S. Apleys System of
Orthopaedics and Fractures. Edisi 9. Great Britain:
Hodder Arnold; 2010.
Source
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