Clinical evaluation of spine
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Can we have some cell phone ettiquette, please ?Can we have some cell phone ettiquette, please ?
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CLINICAL EXAMCLINICAL EXAM
History TakingHistory Taking Keep the question simpleKeep the question simple Ask one at a timeAsk one at a time Get an answer before proceeding to next oneGet an answer before proceeding to next one Avoid putting words into patients mouthAvoid putting words into patients mouth Give equal value to awkward pointsGive equal value to awkward points
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CLINICAL EXAMCLINICAL EXAM
MANDATORY QUESTIONSMANDATORY QUESTIONS
CERVICAL REGIONCERVICAL REGION ? VERTIGO,BLACKOUT,DROP ATTACK? VERTIGO,BLACKOUT,DROP ATTACK H/O URT INFECTION (IN JUNIORS)H/O URT INFECTION (IN JUNIORS) H/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTSH/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTS
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CLINICAL EXAMCLINICAL EXAM
THORACIC REGIONTHORACIC REGION ? NEUROLOGICAL SIGNS IN LOWER ? NEUROLOGICAL SIGNS IN LOWER
LIMBSLIMBS
LUMBAR REGIONSLUMBAR REGIONS ? PERINEAL ANAESTHESIA? PERINEAL ANAESTHESIA ? CHANGE IN MICTURITION HABITS? CHANGE IN MICTURITION HABITS ? SPHINCTER TROUBLE? SPHINCTER TROUBLE
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CLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
SymptomsSymptoms
Pain-Neck itself / Ref. To shoulder & armsPain-Neck itself / Ref. To shoulder & arms Relation to PostureRelation to Posture StiffnessStiffness
Intermittent / continuousIntermittent / continuous DeformityDeformity
Neck fixed in flexionNeck fixed in flexion
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CLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
Numbness, tingling & weaknessNumbness, tingling & weakness Headache-suspect other causesHeadache-suspect other causes ““Tension”- ‘Try to read’ the patientsTension”- ‘Try to read’ the patients Target zone for psychosomatic illnessTarget zone for psychosomatic illness
TWO ARMS = ONE NECKTWO ARMS = ONE NECK (If both arms are affected suspect (If both arms are affected suspect
neck)neck)
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CLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
LookLook - Deformity- Deformity FeelFeel - Tender areas in muscles /front- Tender areas in muscles /front
- Cervical rib- Cervical rib MoveMove - Forw.flex / ext / lat.flex / rotation- Forw.flex / ext / lat.flex / rotation PulsesPulses - Radial - at rest – on traction- Radial - at rest – on traction NeuroNeuro - Mandatory in upper limbs- Mandatory in upper limbs X-rayX-ray - AP / Lateral- AP / Lateral
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EXAMINATIONEXAMINATION
FLEXION / EXTENSION / ROTATION TILT / TESTING POWER ELBOW & WRIST
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READING A LAT.FILM OF C.SPINEREADING A LAT.FILM OF C.SPINE
ALIGNMENT ALIGNMENT BONY INTEGRITYBONY INTEGRITY CARTILAGINOUS SPACESCARTILAGINOUS SPACES SURROUNDING SOFT TISSUESSURROUNDING SOFT TISSUES PRE VERTEBRAL SOFT TISSUE PRE VERTEBRAL SOFT TISSUE
SHADOWSHADOW BLOOD / FLUID / PUS / TUMOR MATERIALBLOOD / FLUID / PUS / TUMOR MATERIAL
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ANATOMY OF C - SPINEANATOMY OF C - SPINE
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TORTICOLLIS
NATURAL HISTORY
EARLY DEFORMITY
STERNOMASTOID DIVIDED
RESULT AFTER SURGERY
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SPASMODIC TORTICOLLIS - NOTE THE MUSCLE IN SPASM
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CERVICAL DISC LESIONCERVICAL DISC LESION
STRAIGHTENING OF LORDOSIS / MRI SCAN SHOWS C5/6 DISC
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CERVICAL SPONDYLOSISCERVICAL SPONDYLOSIS
DISC DEGENERATION & OSTEOPHYTES
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PYOGENIC INFECTIONPYOGENIC INFECTION
DESTRUCTION TAKES 2 TO 3 WEEKS
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RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS
BEWARE OF ATLANTO - AXIAL SUBLUXATION
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NEURALGIC AMYOTROTHYNEURALGIC AMYOTROTHY
WASTING – WEAKNESS MAY BE PERMANENT
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CERVICAL RIB CERVICAL RIB
UNILATERAL / BILATERAL PULSATING LUMP / TEACH SHRUGGING EXCERCISES
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MALIGNANT DEPOSITS MALIGNANT DEPOSITS
NOTE THE PAN - COAST TUMOUR
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OTHER CAUSES OF NECK & ARM PAINOTHER CAUSES OF NECK & ARM PAIN
CARPAL TUNNEL SYNDROME
SUPRA SPINATUS TENDON LESION
CERVICAL TUMOURS
THORACIC OUTLET SYNDROME
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THORACIC SPINETHORACIC SPINE
LOOK LOOK -- DEFORMITIESDEFORMITIES FEELFEEL - - TENDERNESSTENDERNESS NEUROLOGYNEUROLOGY -- TB / PYOGENIC TB / PYOGENIC
/ /
-- METASTASISMETASTASIS TRACKING OF COLD ABSCESSTRACKING OF COLD ABSCESS
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CONGENITAL MYELODYSPLASIA
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SCHEUERMANN’S THORACIC KYPHOSIS
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SCHEUERMANN’S LUMBAR KYPHOSIS
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PARALYTIC SCOLIOSIS
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OTHER CAUSES OF SCOLIOSIS
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CLINICALEVALUATION
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ANATOMY OF SPINAL NERVES
NOTE THE RELATIONSHIP OF DISC TO THE ROOTS
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YOU STAND ON S1 & SIT ON S3
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PRIMARY MUSCLE ACTIONPRIMARY MUSCLE ACTION
HIP FLEXION – PSOAS / ILIACUS = L 2 / 3HIP FLEXION – PSOAS / ILIACUS = L 2 / 3
KNEE EXTEN – VAST INTER = L 3 / 4KNEE EXTEN – VAST INTER = L 3 / 4
ANKLE FLEX – SOLEUS = S 1 / 2ANKLE FLEX – SOLEUS = S 1 / 2
EXCEPTIONEXCEPTION E H L – L 5 ROOTE H L – L 5 ROOT
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EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
PAIN - SCIATICA / PAIN - SCIATICA / COUGH / SNEEZECOUGH / SNEEZE STIFFNESS – DISC / A S / ARTHRITISSTIFFNESS – DISC / A S / ARTHRITIS DEFORMITYDEFORMITY NUMBNESS & / PARAESTHESIANUMBNESS & / PARAESTHESIA ASK ASK WALKING / STANDING / WALKING / STANDING / REST REST ? URETHRAL DISCHARGE/ DIARRHOEA / ? URETHRAL DISCHARGE/ DIARRHOEA /
SORE EYESSORE EYES
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EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
LOOKLOOK – SKIN SCARS / PIGMENTATION – SKIN SCARS / PIGMENTATION
ABNORMAL HAIRS / UNUSUAL SKIN CREASEABNORMAL HAIRS / UNUSUAL SKIN CREASE
SHAPE & POSTURE AFFECTEDSHAPE & POSTURE AFFECTED FEELFEEL – BONYSTRUCTURES / I V TISSUE / PARA – BONYSTRUCTURES / I V TISSUE / PARA
MUSCLESMUSCLES MOVEMOVE – FLEX / EXTD / LAT. BEND / ROTATION – FLEX / EXTD / LAT. BEND / ROTATION
CHEST EXPANSIONCHEST EXPANSION MUSCLE POWERMUSCLE POWER – –
STAND ON TOES STAND ON TOES (PLANTAR FLEXION)(PLANTAR FLEXION)
ROCK BACK ON HEELS ROCK BACK ON HEELS (DORSIFLEXION)(DORSIFLEXION)
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EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
IMAGING – IMAGING – X – RAYSX – RAYS PLEASE PREPARE BOWEL PLEASE PREPARE BOWEL
AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.
COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY BONE TUMOUR / Sp.CANAL STENOSISBONE TUMOUR / Sp.CANAL STENOSIS
MRI SCANMRI SCAN – FOR SOFT TISSUE – FOR SOFT TISSUE
BEWARE FALSE POSITIVE FINDINGS ( >30%)BEWARE FALSE POSITIVE FINDINGS ( >30%)
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EXAMINATION
STANDS WITH A TILT / LTD FORW. FLEX / LAT. FLEX
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EXAMINATION
METHOD OF MEASURING EXCURSION
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LYING ON HIS BACK
SLRSTRETCH+
HIP & KNEE
EHL
SENSATION
REFLEX
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HERNIATED LUMBAR DISC
CHARACTERISTIC POSTURE
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L3/4 DISCL4 ROOT
L4/5 DISCL5 ROOT
L5/S1 DISCS1 ROOT
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SPINE TUBERCULOSIS
SHOWING PROGRESSIVE DESTRUCTION
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SPINE TUBERCULOSIS
PATHOLOGICAL DESTRUCTION & ABSCESS
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PYOGENIC SPONDYLITIS
EVIDENCE OF BONE DESTRUCTION + +
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MOBILE SCOLIOSIS
POSTURAL FLEXION
SHORTLEG SITTING
PROLAPSED DISC ON TTMT
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FIXED SCOLIOSIS
INCREASING CURVE OVER THE YEARS
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INFANTILE THORACIC
ADOLESCENT THORACIC
THORACO - LUMBAR
LUMBAR
COMBINED
IDIOPATHIC SCOLIOSIS
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TRANSITIONAL LUMBO-SACRAL VERTIBRA
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SPODYLOLYSIS & SPONDYLOLISTHESIS
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ANKYLOSING SPONDYLITIS
REDUCED CHEST EXPANSION / OSSIFIED LIGAMENTS
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DEGENERATIVE OSTEO ARTHRITIS
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SPINAL CANAL STENOSIS
CLINICAL FEATURES
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MECHANICAL CAUSES OF LOW BACK PAIN
GOOD POSTURE & POOR POSTURE
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EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
EXTENSIVE LAB TESTEXTENSIVE LAB TEST
WHEN CLINICIAN SUSPECTSWHEN CLINICIAN SUSPECTS
MALIGNANCY MALIGNANCY
METABOLIC DISTURBANCEMETABOLIC DISTURBANCE
CHRONIC INFECTIONCHRONIC INFECTION
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TUMOURS OF SPINE
OSTEIOD OSTEOMA HEMANGIOMA
BENIGN LESIONS
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MYELOMA
SECONDARY TUMOURS
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EXTRA DURALFIBROBLASTOMA
EXTRAMEDULLARY MENINGIOMA
INTRA MEDULLARY EPENDYMOMA
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CHRONIC BACKACHECHRONIC BACKACHE
TB OM DISCITIS
SI Jt. TB OST. CONDENS. ILII
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PSYCHOSOMATIC MANIFESTATION
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“ From the unreal lead me to the real ! From darkness lead me to light ! From death lead me to immortality ! Brihad – aranyaka Upanishad
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Thank YouThank You
© Dept. of © Dept. of OrthopaedicsOrthopaedics,,Govt. Medical College, Govt. Medical College, ThrissurThrissur