DR.RANVIR SAACHIN

Basic Vertebral Structures

Cervical Thoracic Lumbar

Cervical Lordosis 20°- 40°

Sacral Kyphosis

Lumbar Lordosis 30°- 50°

Thoracic Kyphosis 20°- 40°

Vertebral Body

Pedicle

LaminaSuperior Articular Process

SpinousProcess

Transverse Process

Vertebral Foramen

Superior ArticularProcess

Inferior ArticularProcess

ZygapophysealJoint

(Facet Joint)

Pars

Pedicle notchesSlight Notch

Deep Notch

Intervertebral Foramen

• INTERVERTEBRAL FORAMEN

through which the spinal nerve roots leave the spinal cord

1. GAIT

NORMAL WALKING

WALKING ON TIP TOES – S1 WEAKNESS

WALKING ON HEELS - L5 WEAKNESS

(A) Look From Side

Normal spine

> cervical lordosis

> thoracic kyphosis

> lumbar lordosis

2.Increased kyphosis (posterior convexity of

the spine)

> senile kyphosis (with osteoporosis,

osteomalacia or pathological fracture)

> Scheuermann’s disease (osteochondritis

involving one or more of the vertebrae)

> ankylosing spondylitis

iii. Gibbus (angular kyphosis)

> fracture

> tuberculosis of the spine

> congenital abnormality

iv. Lumbar curvature

> flattening or reversal of lumbar lordosis :

- prolapsed intervertebral disc

- osteoarthritis of the spine

- infection of vertebral bodies

- ankylosing spondylitis

> increase in lumbar lordosis

- may be normal (esp. in women)

- spondylolisthesis

- secondary to increased thoracic curvature

or to flexion deformity of the hips

(b) Look from behind

i. listing of trunk (due to muscle spasm)

ii. Scoliosis (lateral curvature of spine)

- postural : scoliosis disappears with

forward flexion of the spine

- structural : scoliosis persists with forward

flexion of the spine and a rib hump

presents

iii. Shoulder tilt

iv. Pelvic tilt

v. Skin changes over the spine

- hair tuft (spina bifida)

- sinus

- colour changes or pigmentation (neurofibroma)

- scar

vi. Swelling

vii. Prominent crease of the trunk

viii. Wasting of glutei, hamstrings and calf muscles

along the spinous process, looking for

tenderness

paravertebral muscle spasm

sacro-iliac joint tenderness

step deformity (spondylolisthesis)

- Slide the fingers down the lumbar spine on to the

sacrum

- A palpable step at the lumbo-sacral junction

Thoracic and Lumbar spine

Flexion

- ask the patient to try to touch his toes

- watch the spine for smoothness of movement and any areas of restriction

- patients with advanced ankylosing spondylitishave a flat ankylosed spine and all the bending occur at the hips

Lumbar spine excursion test (Schober’s

method)

- Mark 2 points 10cm apart at the midline of

lumbar spine

- Anchor the top of the tape with a finger and ask

the patient to flex as far as he can

- Measure the increase in the distance between

the 2 points which indicate lumbar excursion

- Normal excursion = 5 cm or more

2. Extension

- ask the patient to arch his back

- assist him by steadying the pelvis and pulling

back on the shoulder

- normal : 30

3. Lateral flexion

- ask the patient to slide the hands down the side of each leg in turn

- record the point reached from the floor or

- measure the angle

- normal : 30-45°

4. Rotation

- patient seated to fix the pelvis or pelvis fixed

by examiner

- ask the patient to twist round to each side

- normal : 45°

UPPER LIMB

1. Tone

2. Power

3. Reflexs

4. Sensation

Tone

Power

Nerve root Test

C5 Elbow flexion

C6 Wrist extension

C7 Wrist flexion

C8 Finger flexion

T1 Finger abduction

1. Tone

Hypertonia - UMNL

Hypotonia - LMNL

2. Power

i. Shoulder

- abduction : C5,C6

- adduction : C6,C7,C8

ii. Elbow

- flexion : C5,C6

- extension : C7,C8

iii. Wrist

- flexion : C6,C7

- extension : C7,C8

iv. Fingers

- flexion : C7,C8

- extension : C7,C8

- abduction : C8,T1

- adduction : C8,T1

3. Reflex

- biceps jerk : C5,C6

- triceps jerk : C7,C8

- brachioradialis (supinator) jerk : C5,C6

4. Sensation

C5 – lateral arm

C6 – lateral forearm

- thumb & index finger

C7 – middle finger

C8 – ring&little finger

T1 – medial arm

LOWER LIMB

1. Tone

hypertonia : UMNL

normotonia

hypotonia : LMNL

Power i. Hip

- flexion : L2,L3

- extension : L5,S1,S2

- abduction : L4,L5,S1

- adduction : L2,L3,L4

ii. Knee

- flexion : L5,S1

- extension : L3,L4

iii. Ankle

- plantar flexion : S1,S2

- dorsiflexion : L4,L5

iv. Tarsal joint

- eversion : L5,S1

- inversion : L5,S1

3. Reflex

- knee jerk : L3,L4

- ankle jerk : S1,S2

- plantar reflex : L5,S1,S2

1. Straight leg raising test

- do on normal limb 1st

- raise the leg from the couch with the knee extended until the patient experiences pain (over the back & may radiate to the lower limb)

- Distribution of the pain indicating the involved nerve root

- Positive if the angle < 60°

- Cross sciatic tension : severe root irritation(pain on the affected side when raising the unaffected

leg)

2. Sciatic Stretch Test

- Following SLR test

- Drop the limb about 10° to relieve tension on

the irritated nerve root

- Dorsiflex the ankle to reproduce the same pain

3. Femoral Stretch Test

- For lumbar root sensitivity

- Patient should be prone

- Flex the patient’s knee and lift the hip into

extension

- Pain may be felt in front of the thigh and in the

back

Bowstring Test

Subject begins supine with legs extended Examiner performs a passive straight leg raise on the involved side If radiating pain is reported, the examiner then flexes the subjects knee until symptoms are reduced The examiner then applies pressure to the poplitealarea in attempt to reproduce the radicular pain

Pelvic rock test

Compress pelvis to midline- +ve if pain in SI joint

Gaenslens sign

Supine, patient draws both knees up to chest, then shift patient to side of couch so one buttock extends over edge. Allow unsupported leg to drop over edge while opposite leg remains drawn up to chest- +ve if pain in SI joint

Faber test(Flexion, abduction external rotation)

supine, place foot of involved side on opposite knee ( fig 4 position). To stress SI joint press down on knee with one hand & press down on opposite ASIS with the other hand

Examination of other joints

Rectal examination

THANK YOU