Cervical spine
Consist of 7 vertebra
8 nerves
Give two plexuses
Cervical plexus ( C1-C5) brachial plexus ( C5-T1)Phernic ( C3,C4,C5) mucocutanous n (C5-C7)
Lesser occipital (C2) axillary n (C5-C6)
Supraclaviclular ( C3,C4) median n (C5-T1)
radial N (C5-T1)
ulnar n (C8-T1)
Cervical spine
History * acute traumaHistory of Falling down , vehicle accident .
Any patient unconious form after heard injury you should assumed it as cervical spine injury.
ABC, WAIT FOR help , x –ray frontal & lateral
Cervical spine
History * PAIN :- analysis of pain
Acute ,sub acute ,chronic
Onset ,duration , character , severity ,radiation ,reliving ,aggravating factor
At end of day /at night , other joint affected
*Weakness in upper limb
*Paraesthesia
Cervical spine
History
Pain and difficulty turning the head and neck, examples are:
→ Disease of atlanto-occipital joints produces pain radiating to the occiput.
→ Spondylosis of the middle and lower cervical spines causes pain radiating to the upper border of trapezius, interscapular region, and the arms.
→ Irritation of the C6 & C7 nerve roots can give rise to referred pain in the interscapular region, radial fingers, and thumb.
→ Irritation of C8 can cause pain on the ulnar side of forearm, ring, and little fingers.
Cervical spine
Physical examination:
Look
Observe the posture of the head and neck and note any abnormality and deformity, e.g. loss of lordosis.
Feel
→ The midline spinous processes
→ The paraspinal soft tissues
→ The supraclavicular fossae – for cervical ribs or enlarged lymph nodes
→ The anterior neck structures including the thyroid
Move: → Assess active movements:
o forward flexionPut your chin on your chest
o Extensionlook upwards at the ceiling as far back as you can
o Lateral flexionPut your ear onto your shoulder
o Lateral rotationLook over your right/left shoulder
→occiput to wall test → Gently perform passive movements if there are
reduced active movements and see if the end of the range has a sudden or gradual resistance and whether it is pain or stiffness that restricts movements
Cervical spinePhysical examination – Cont. ( Neuro exam):
MovementC5- shoulder abductionC6 – elbow flexion wrist extension
C7- wrist flexionREFLEXES:-Deltoid (C5)BICEPS (C6)TRICEPS (C7)
Sensory C2,C3 neck shoulderC3,C4 shoulder posteriorARM Medially T1Laterally C5 ,C6FOR ARMT1 MEDIALLY C6 laterallyHANDLateral C6Middle finger C7MEDIALLY C8
Thoracic spine( T1-T12)
History
→ Commonly, localized spinal pain, examples are: Ankylosing spondylitis produces pain in the thoracolumbar region Acute thoracic spinal pain may be due to vertebral prolapse due to
malignancy, or infection; especially if there was systemic upset or fever is present
→ Less commonly, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control
Thoracic spine
Physical examination:
Look With the patient standing, inspect posture from behind, the side and the
front, noting any deformity, e.g. rib hump or abnormal curvature. Feel → The midline spinous processes → The paraspinal soft tissues → If there is increased prominence of one or more spinous processes
implying anterior wedge-shaped collapse of the vertebral body – often related to osteoporosis.
Move Ask the patient to sit with arms crossed, and to twist round and look at you.
Lumbar spineLUMBAR NERVES( L1-L5)
SACRAL NERVES ( S1-S4)
LUMBAR PELUXES ( L1-L4)
illioingunal (L1) , iliohypogastric (L1) , genitofemoral (L1-L2), Femoral (L2-L4)
Obuturator (L2-L4)
SACRA L PELUXES
SCIATIC NERVE (L4 –S3)
1- Common peroneal
2- Tibia
Lumbar spineSCITICA :- PAIN extend from buttock , poster-lateral of leg , lateral aspect of foot
Common risk factor :-
1-Herniated disc
2- pregnancy
3-osteoarthritis
4- wrong IM INJECTION
Lumbar spine
History
→ Low back pain is an extremely common complaint
→ Sacroilitis produces pain that is referred down both legs to knees
→ Consider abdominal and retroperitoneal pathology, e.g. abdominal aortic aneurysm, pancreatitis, peptic ulcer, renal pathologies.
Lumbar spine
Red flag features for acute low back pain:
→ In History: Age < 20 yrs or > 55 years Recent significant trauma (fracture) Pain:
Thoracic (dissecting aneurysm) Non-mechanical (infection/ tumor/pathological fracture) Fever ( infection) Difficult micturition Fecal incontinence Motor weakness Saddle anesthesia Sexual dysfunction Gait change ( cauda equina syndrome) Bilateral sciatica
Lumbar spine
Red flag features for acute low back pain:
→ In Past medical History: Cancer ( metastasis.)Previous steroid use (osteoporotic collapse)
→ In Systemic review:
Weight loss/malaise without obvious cause (e.g. cancer)
Lumbar spine
Physical examination:
Look
Examine the patient standing. Look for obvious abnormality such as decreased/increased lordosis, obvious scoliosis soft tissue abnormalities such as a hairy patch or lipoma that overlie spina bifida.
Feel
Palpate the spinous processes and the paraspinal tissues. The L4/L5 interspinous space is palpable at the level of iliac crests.
Move → Flexion: ask the patient to
try to touch his toes with his legs straight
→ Extension: ask the patient to straighten up and lean back as far as possible
→ Lateral flexion: ask the patient to reach down to each side touching the outside of the leg as far down as possible while keeping the legs straight
LUMBER SPINEPhysical examination – Cont. ( Neuro exam):
MovementL2- hip flexionL3 – Knee extention L4-dorsiflexion S1-planterflexion
REFLEXES:-Quadriceps (L3-L4)Achilles (l5-s1)
Sensory
Lumbar spinePhysical examination-Cont.:
Special tests: Schober’s test for forward flexion Root compression tests:
Straight leg raise Tibial nerve stretch test Femoral nerve stretch test Flip test
Sacroiliac joints test
Lumbar spine
Schober’s test for forward flexion1- Erect position. 2- Select 2 bony points,10cm apart and mark it.3-Maximum flexion on lumbar with fix knee.4-the two points should separate by at least a further
5cm.
Schober’s test
Straight –Leg raising test
-knee straight,slowly lifted the leg.
-note for any tightness and pain in the buttock (around 80-90 )
-passive dorsiflexion,increase the pain.
-bow-string sign : bending the knee slightly,release the pain.then apply firm pressure behind lateral hamstring,pain will recur.
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• Hematological : erythrocyte sedimentation rate, complete blood count
• Biochemical : C-Reactive protein , Ca level , ALP• Serological : RF , ANA• X- ray• CT scan• MRI• Isotope bone scan• Ultrasound