General examination of the spine
Sometimes, it's not precisely clear what has lead to the irritation. Symptoms and exam findings for lumbar and sacral root pathology are described below. Of note, L5 and S1 are the most commonly affected roots. Pain radiates from the low back to the upper leg. If there are sensory deficits, they will affect the lateral and anterior upper thigh.
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If there is weakness, it will affect the quadriceps knee extension and psoas hip flexion muscles. Pain radiates from the low back to upper leg. If there are sensory deficits, they will affect the lower medial thigh. If reflexes are affected, the patellar will be impaired. Pain radiates from the low back to below the knee. If there are sensory deficits, they will affect the medial aspect of the lower leg. If there is weakness, it will affect the quadriceps knee extension muscle. If there are sensory deficits, they will cause numbness on the top of the foot. If there is weakness, it will affect foot inversion and great toe extension.
If there are sensory deficits, they will affect the lateral aspect of foot. If there is weakness, it will cause impaired plantar flexion. If relexes are affected, the achilles will be impaired. Pain starts in the low back and radiates down the buttocks bilaterally, continuing along the backs of both legs.
Symptoms are usually worse with walking and improve when the patient bends forward. Patient's may describe that they relieve symptoms by leaning forward on their shopping carts when walking in a super market. This is caused by spinal stenosis, a narrowing of the central canal that holds the spinal cord. The limited amount of space puts pressure on the nerve roots when the patient walks, causing the symptoms referred to as neurogenic claudication.
Spinal stenosis can be congenital or develop over years as a result of djd of the spine.
Also, peripheral pulses should be normal. In some patients, more then one process may co-exist, causing elements of more then one symptom syndrome to co-exist. These problems carry significant morbidity and mortality and mandate a focused and rapid evaluation including lab and imaging studies different from what is required for the relatively benign processes described above. Careful history taking and examination can help distinguish these problems. Pain associated by systemic symptoms of inflammation e.
Spine examination – OSCE Guide
IV drug users, patients with bacteremia. Known history of cancer, in particular malignancies that metastasize to bone e. Trauma, particularly if of substantial force. Osteoporosis, which increases risk of compression fracture vertebrae collapsing under the weight they must bear.
Anything suggesting neurological compromise. In particular, weakness in legs suggesting motor dysfunction.
Also, bowel or bladder incontinence, implying diffuse sacral root dysfunction. Pain referred to the back from other areas of the body e.
In particular, pain may be reflected by increase pulse, BP or pain score if asked. Also, temperature if concern re an infectious process. Is it slow, limited by pain? Look at the lumbar spine area. Any skin abnormalities suggesting underlying inflammation? Normal curvature is as follows: Cervical spine sweeps anteriorly, thoracic spine sweeps posteriorly, and lumbro-sacral spine sweeps anteriorly. Range of motion testing should include forward flexion, hyperextension, lateral flexion, and rotation. Can the patient point to the precise area of the pain?
Is it along the vertebral column? Para-spinal, as might occur with spasm? Radiating down the legs as would occur with nerve root irritation? Processes that inflame the bone e. Spine Percussion Is the pain in the costo-vertebral angle area, suggestive of a kidney infection? Location of kidneys drawn on back.
In the setting of kidney infection pyelonephritis , percussion over this area will cause pain.
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If the patient's complains of a radiating type pain down one leg, suggestive of nerve root irritation, proceed as follows: Ask the patient to lie down on their back. Have the patient completely relax the affected leg. Cup the heel of their foot and gently raise the leg. If there is nerve root irritation, the patient will experience their typical pain when the leg is elevated between 30 and 60 degrees. That being said, as with any art form, having an appropriate resource to reference and guide one's experience is vital to success.
Neurosurgery | Physical Examination of the Spine
Written by world-renowned spine surgery experts, this definitive text elucidates the importance of obtaining a thorough medical history and performing a physical exam for a full spectrum of spine conditions. There have been significant advancements in minimally invasive spinal surgery techniques since publication of the last edition. However, spine evaluations will always be imperative to clinical practice. These exams reveal a myriad of clues that help spine specialists make a differential diagnosis for a wide array of pathologies.
This book is a clear, concise "how to" guide on conducting physical examinations of the spine. The text begins with a methodical review of fundamentals including basic anatomy and neurology; sensation, muscle, and reflex tests; and classification systems. Subsequent chapters succinctly delineate why the spinal exam is an integral component of neurosurgical, neurological, orthopaedic, and chiropractic exams.
Up-to-date and comprehensive, this book is essential reading for trainee and practicing orthopaedic surgeons and neurosurgeons who perform spine tests in daily practice. It is also a terrific resource for neurologists, physical therapists, and allied health professionals who frequently treat patients for back and neck pain.