Transcript Lateral flexion

EXAMINATION
OF THE
SPINE
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SYMPTOMS
Pain
Sciatica
Stiffness
Deformity
Numbness or paraesthesia
Urinary symptoms
Other
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How to Start
IPEEP
INTRODUCE.
PERMISSION.
EXPLANTION.
EXPOSURE.
POSITION.
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The Apley System
All joint examinations follow this 
system:
Look 
Feel 
Move : Active then Passive 
Special Tests 
Radiograpgy. 
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Patient
in
standing
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INSPECTION
BONE CONTURES. 
SOFT TISSUE CONTOURES. 
COLOUR AND TEXTURE OF THE SKIN. 
SCARS OR SINUSES. 
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PALPATION
SKIN TEMPERATURE. 
BONE CONTOURS. 
SOFT TISSUES CONTOURS:
Palpate swellings 
LOCAL TENDERNESS. 
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MOVEMENTS
Spinal joints : 
FLEXION . 
EXTENSION. 
LATERAL FLEXION. 
ROTATION. 
PAIN ON MOVEMENT. 
MUSCLE SPASM. 
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MOVEMENTS
Costo-vertebral joints 
Ranged indicated by chest expansion. 
Sacroiliac joints 
Pain on movement imparted by lateral compression of 
pelvis.
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FLEXION .
Instruct the patient to stretch his fingers towards
hIs toes, keepIng the knees straight.
It is important to Judge what proportion of the
movement occurs at the spine and how much IS
contrIbuted by hIp flexion Some patients can
almost reach their toes, despite a stiff back,
simply by flexing unusually far at the hips.
(Normally the hamstrings limit hip flexion to
about 90 degrees when the knees are straight.)
The range may be expressed as a percentage of
the normal,. or
as the distance by which the fingers fall to reach
the floor.
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Apparent or
false flexion
Normal flexion of
lumbar spine
Apparent or false
flexion
due entirely to movement at 
the hips,
the hamstrings being 
unusually lax. In estimating
trunk flexion it is important 
to judge how much of the
movement occurs at the
spinal joints and how much 
at the hips.
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EXTENSION
Instruct the patient to arch the
spine backwards, lookIng up at
the ceiling.
Judge the range and express
approximately as a percentage of
the normal.
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Lateral flexion
Instruct the patient to
side each hand In
turn down the lateral
side of the
corresponding thigh.
Observe the
range.
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Rotation:
With the feet fixed, the patient
rotates the shoulders
towards each side in turn.
Note the range of spinal
rotation as distinct
from that which occurs at the
knees and hips.
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Examination of the patient
in recumbent
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Palpation of the iliac
fossa.
Examine specifically
for abcess.
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Palpation of the iliac fossae and groins is an essential step 
in the
It should be remembered
that a 'psoas' abscess originating from a tuberculous lesion 
of the
lumbar spine first becomes palpable deep in the iliac fossa. 
Such an
abscess is felt most easily by pressing the flat palmar 
surface of the hand
and fingers against the flat inner aspect of the iliac bone 
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Signs with patient lying face downwards
Bony outlines 
Tenderness 
Sensations and Power 
Femoral stretch test 
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Femoral stretch test
Looking for femoral nerve root irritation 
L2-4
Patient prone, ant thigh fixed to couch, flex 
each knee
Pain felt in anterior compartment of the 
thigh
Aggravated further by extension of hip 
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NEUROLOGICAL STATE OF LOWER
LIMB
Straight leg rasing test.
Muscular system.
Sensory sysytem.
Reflexes.
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Signs with patient lying on his back
Straight leg raising test (sciatic stretch) 
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Straight leg raising test
Holding the knee straight, lift each lower 
limb in turn to determine the range of pain-free movement (normal 
= 90 degrees; often more in women) 
When associated with 
clearly defined sciatica (and in the absence of gross disease of the hip), 
marked Impairment of straight leg raising by pain suggests mechanical 
Interference wIth one or more of the roots of the sciatic nerve. 
The 
pain is easily explained. 
Even a normal sciatic nerve is tautened by 
straight leg raising, though not to the point of causing pain by 
dragging on the meningeal sheath that encloses the nerve root. 
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NORMALLY
UP TO
90 DEGREE
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Cutaneous distribution of nerve roots
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Circulation in the limbs 
Femoral artery pulsation 
Popliteal artery pulsation 
Dorsalis and posterior tibial artery pulsation 
Rectal examination 
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Muscular system
Examine the muscles for wasting,
hypertrophy, and fasciculation.
Note the tone.
and test the power ,
comparing it with its counterpart
in the opposite 11mb.
Circumiferential measurement is a
reliable method of comparing
(calf muscles and thigh, the girth
being measured at the widest part
or equator
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Muscle Power Testing
MRC Scale
Total paralysis
0
Barely detectable contracture
Not enough to act against gravity
Strong enough to act against gravity
Still stronger but less than normal
Full power
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5
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SENSORY SYSTEM
For touch ,
pin prick.
Deep stimuli .
Joint position.
Vibration.
Heat and cold
examination
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SWEATING.
Feel the digit if it is moist , or dry.
Sweating depend upon intact sudomotor nerve fibers.
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REFLEXES
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The patellar reflex is dependent
mainly on L.4 nerve
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Testing the calcaneal reflex
(mainly S. I nerve),
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Examination of potential extrinsic
sources of neck symptoms.
Examination should include.
Abdomen,
pelvis,
rectal examination,
lower limbs
Peripheral vascular system.
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Sometimes there are no local symptoms to indicate that the 
spine is the seat of the disorder,
Pain referred entirely to the buttock or to the lower 11mb. 
often complain only of pain 'in the hip' or 'in the leg' when 
true source of the trouble is the lumbar spine.
Conversely, the symptoms may suggest a spinal lesion when 
in fact they arise from abdomen, pelvis, or lower limb, or
from occlusion of artery or a leaking aortic aneurysm.
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Imaging
Plain x-rays 
AP and lateral views 
Oblique views 
PA view of S.I. Joint 
Computed tomography (with mylography) 
MR imaging 
Radioisotope scanning 
Discography and facet joint arthrography 
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CLASSIFICATION OF DISORDERS OF
THE
TRUNK
AND
SPINE
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CONGENIT AL ABNORMALITIES
Lumbar and sacral variations
Hemivertebra
Spina bifida
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DEFORMITIES
Scoliosis
Kyphosis
Lordosis
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INFECTIONS OF BONE
Tuberculosis of the thoracic or lumbar spine 
Pyogenic infection of the thoracic or lumbar spine 
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ARTHRITIS OF THE SPINAL JOINTS
Rheumatoid arthritis 
Osteoarthritis 
Ankylosing spondylitis 
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OSTEOCHONDRITIS
Scheuermann's vertebral osteochondritis 
Calve's vertebral osteochondritis 
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MECHANICAL DERANGEMENTS
Prolapsed lumbar intervertebral disc 
Acute lumbago 
Spondylolysis 
Spondy lolisthesis 
Spinal stenosis 
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TUMOURS
Tumours in relation to the 
cord, or nerve roots 
Other tumours of the trunk 
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CHRONIC STRAINS
Chronic lower lumbar ligamentous strain 
Coccydynia 
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MISCELLANEOUS
Fibrositis 
Senile osteoporosis 
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DISORDERS OF THE SACRO- ILIAC JOINTS
Tuberculosis of a sacro-iliac joint 
Ankylosing spondylitis 
Other forms of arthritis 
Sacro-iliac ligamentous strain 
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