Spine

Cervical Spine Exam

Require

 

1.  Diagnose Myelopathy

- heel toe

- Rhomberg

- finger escape

- clench and release

- high tone

- inverted BR / Hoffmans

 

2.  Identify Neurology

 

Look 

 

Front

- Position of head & neck

- Torticollis

- SCM tumour

- wasting limbs

 

Side

- Kyphosis

- Webbed neck

 

Back

- Low posterior hairline

- Sprengel shoulder

- Wasting Peri-scapular

 

Gait 

 

Toe walking (S1)

Heel walking  (L4)

 

Toe-to-heel walking

- looking for balance difficulty

- ataxia

 

Romberg

- assess dorsal column / proprioception

- stand feet together, close eyes

- positive if sway or fall

 

Finger escape

- hold hands out

- try to keep LF together with other fingers

 

Clench and release

- should be > 20 times in 10 seconds

 

Feel

 

Spinous processes

Paravertebral - trapezius

Posterior triangle

Sternomastoid

 

Move

 

Forward flexion

- Chin to chest

- Total range of F/E is 130°

- Alanto Occiptial Joint (40% Nodding) / Subaxial (60% Forward translation)

 

Extension

- Plane of nose & forehead horizontal

 

Rotation

- Chin nearly to plane of shoulder 80°

- Atlantoaxial Joint (50%) / Subaxial (50%)

 

Lateral Flexion 

- Ear to shoulder with shrug 45°

- Occurs at lower Cervical vertebrae

 

Special Tests

 

Spurling's Sign

- Nerve root compression is confirmed by Spurling's sign 

- extension and rotation toward the symptomatic side reproduces the radicular symptoms

 

Thoracic Outlet Syndrome Tests

- Addsons

- Roos

 

Neurological Exam

 

Tone

 

High tone / clasp knife rigidity

 

Power

 

C5 - Deltoid / Biceps

C6 - Wrist Extension

C7 - Triceps

C8  - Finger Flexion

T1 - Interossei

 

Reflexes

 

C5 - Biceps

C6 - Brachioradialis

C7 - Triceps

 

Myelopathy reflexes

 

Inverted Brachioradialis

- tap on BR

- flexion of thumb and index finger

 

Hoffmann's reflex 

- forced flexion of MF DIPJ

- reflex finger and thumb flexion is elicited  

 

Scapulohumeral Reflex 

- tapping tip of spine of scapula

- brisk elevation of scapula & abduction of the humerus

- positive in > 95% of myelopaths

 

Jaw Jerk

- a cerebellar sign

- distinguishes myelopathy from cerebellum

 

Sensation

 

C5 - deltoid

C6 - lateral forearm, thumb

C7 - middle finger, posterior arm

C8 - little finger

T1 - medial forearm

T2 - medial arm

 

 

Lumbar Exam

Look

 

Walking / mobility aids

Lumbar brace

AFO / shoes

 

Front

 

Wasting - quadriceps

Manifestations of systematic disease

LLD

 

Side

 

Normal 

- there is a thoracic kyphosis and a lumbar lordosis

 

Abnormal

- exaggerated

- reduced

 

Back

 

Scoliosis

Scars

Signs spinal dysraphism

Wasting - buttocks / thighs / calves

 

Tenderness

- vertebral level

- sacro-iliac joints

 

ROM

 

Forward flexion test

- standing with feet together & knees straight

- aiming to touch floor with hands on legs

 

Comment on

- pain

- level reached (fingertips in relation to front of legs)

- normal unrolling of the lumbar spine

 

Schobar's test

- thumb on LS junction

- line joining dimples of Venus

- reconfirms level pelvis

- index finger 10 cm above

- width of hand

- amount of increased separation of fingers on spine

- should be at least 50%

 

Extension

- one hand in small of back and one hand on shoulder

- normal 15-30°

 

Lateral flexion

- one hand on hip and other hand on shoulder

- normal 15-30°

 

Rotation

- feet still & twist body

- look from above

- angle between plane of shoulders and pelvis

- amount 45°

 

Gait

 

Tiptoes (L5 / S1)

Heels (L4)

Squat / single leg squat (L3)

 

Supine

 

Hip ROM 

- flex hip to 90° and rotate hip

- comment painless range of hip movement

 

SLR

- patient lifts leg actively from bed with knee straight

- at what angle of hip flexion is pain reproduced

- pain must be in distribution of sciatic nerve / below knee

- differentiate from hamstring pain

 

Lasegue

- lower leg until pain just disappears

- forcibly dorsiflex foot and assess if pain recurs

 

Neurological Exam

 

Tone

- normal, increased or decreased

- clonus ankle (normal < 2 beats)

- clonus patella

 

Power

 

L2 - hip flexion / pull knee to chest

L3 - knee extension / hold knee straight

L4 - ankle dorsiflexion / T anterior / pull foot up

L5 - hallux dorsiflexion / FHL / pull big toe up

S1 - ankle plantarfiexion / push foot down

 

MRC Muscle Power Grading

0 - no movement

1 - flicker only

2 - movement with gravity eliminated

3 - movement against gravity

4 - movement against resistance

5 - normal movement

 

Reflexes

 

Knee jerk (L4) 

Ankle jerk (S1) 

Babinski - scratch soles

 

Sensation - light touch

 

LI - groin

L2 - thigh

L3 - knee

L4 - medial malleolus

L5 - bunion / dorsum foot

S1 -  sole / lateral foot

S2 - posterior calf

S3,4 - 'bulls-eye' around perineum

 

Lateral Side

 

Femoral stretch test

- flex knee to 90o

- extend hip

- positive if reproduces leg pain in distribution of femoral nerve

 

Abductor power (L5)

- lift leg up

- palpate contraction

- grade power

 

SI joint

- semilateral position

- leg flexed and adducted across body

- forced adduction

- reproduce pain

 

Special

 

Ankylosing spondylitis 

- wall test

- stand with back to wall

- heels, buttocks and occiput touch wall normal

 

Kyphosis

- forward bending test

- hyperextension while prone

 

Waddell's Signs (DR TOS)

- distracted SLR

- rotation causes pain

- tenderness non anatomical

- overreaction

- superficial tenderness

 

 

Myelopathy Exam

Look

 

Front

- appropriately disrobed / generalised disease / orthotics

 

Side

- sagittal alignment entire spine

 

Back

- wasting / lumbar spine coronal plane alignment / spinal dysraphism

 

Gait

 

Wide based gait

Heel Toe

 

Specific Tests

 

Rhomberg

- arms outstretched in front

- close eyes

- positive if lose balance once visual aids removed

 

Finger escape sign

- hold hands out, fingers together

- medial two fingers drift apart

- takes 30 – 60 seconds

 

Grip and Release / disdiadokinesis

- 20 times in 10 seconds

- myelopathy patients much slower

 

Sit

 

Feel

 

Palpate neck

- central / paraspinal / trapezius / posterior triangle

 

Move

 

ROM

- flexion (should be able to get chin to chest)

- extension (should be able to get forehead parallel to ground)

- ear to shoulder

- rotation 80o

 

Tone

- Cogwheel rigidity

- clonus in feet

 

Power

- ASIA (American Spinal Injury Association)

- look for interosseous wasting

- power often especially decreased in hands

 

Reflexes

- increased / inverted BR / Hoffman / Babinski

 

Sensation

- decreased sensation globally / reduced vibration / proprioception

 

Questions

 

What is differential?

- Central / cerebellar cause / Demyelinating disorder

 

How do you differentiate Cerebellar causes?

- Nystagmus / Jaw Jerk

 

What is treatment?

- Depends on Imaging

- No kyphosis, multilevel degeneration - laminoplasty

- Kyphosis / discs / anterior vertebral osteophytes - ACDF / corpectomy and strut grafting