Download Special tests

PHYSICAL EXAMINATION
OF THE SPINE
Prof. Dr. Şafak Sahir
KARAMEHMETOĞLU, MD.
İU/CMF/PMRD
CERVICAL SPINE
INSPECTION-1
- Lordosis
- Scoliosis
- Swelling
- Torticollis
- Muscle atrophy
INSPECTION-2
- Muscle hypertrophy
- Color changes
- Arterial pulse
- Postural changes
PALPATION-1
* Bone-Joint
- Spinous process
- Interspinous space
- Foramen
PALPATION-2
* SOFT TISSUES
- Swelling
- PVM
- SCMM
- Spinal nerves
- Ligaments
PALPATION-3
* Neighbouring
structures
- Arterial pulse
- Lymph nodules
- Thyroid
- Trachea
- Others
ROM
- Flexion
- Extension
- Lateral Flexion (45°)
- Rotations
- Translations
- Circumflexion
NEUROLOGIC EXAMINATION
- Cervical Plexus
C1-C4
- Brachial Plexus
C5-T1
Cervical Plexus
Has no key muscle, flexors, extensors,
lateral flexors and rotators are tested in groups.
C1: Mainly motor fibres.
C2: Key point: protuberantia occipitalis externa.
C3: Key point: middle of the fossa supraclavicularis.
C4: Key point: acromio-clavicular joint.
Brachial Plexus
C5: KM: biceps, brachialis, KP: lateral of the antecubital fossa, DTR:
biceps.
C6: KM: extensor carpi radialis longus and brevis, KP: middle of the
dorsum of the first phalanx of the thumb, DTR: brachioradialis.
C7: KM: triceps, KP: middle of the dorsum of the first phalanx of the
middle finger, DTR: triceps
C8: KM: flexor digitorum profundus, KP: middle of the dorsum of the
first phalanx of the little finger.
T1: KM: abductor digiti minimi, KP: medial of the antecubital
fossa.
Special Tests -1Distraction: To perform this test, place the open palm of one
hand under the patient’s chin, and the other hand under the
occiput. Then, gradually lift (distract) to remove its weight
from the neck, if the neck and/or arm pain decreases or
disappaers, the test is positive.
It demonstrates the effect that neck traction might have in
relieving pain by widening the foramen, decreasing pressure
on the joints capsules around the facet joints. In addition it
may help to alleviate muscle spasm by relaxing the
contracted muscles.
Special Tests -2Compression: To perform this test, press down upon the top of
the patient’s head while he is either sitting or lying down, if
there is an increase in pain in the neck and/or arm(s), then
the test is considered to be positive.
A narrowing of the neural foramen, pressure on the facet joints
or muscle spasm can cause increased pain. In addition, this
test may reproduce pain referred to the upper extremity
from the cervical helping to locate the neurological level of
any existing pathology.
Special Tests -3Valsalva: To perform this test, have the patient hold his breath
and bear down as he/she were moving his/her bowels. Then,
ask the patient whether he/she feels any increase in pain,
and if so, whether he/she can describes the location. If the
response is accurate, the test is positive.
This test increases intrathecal pressure. If a space occupying
lesion such as a herniated disc or a tumor, is present in the
cervical canal, the patient may develop pain in the cervical
spine. The pain may also radiate according to the
neurological level.
Special Tests -4Swallowing: Difficulty or pain upon swallowing
can sometimes be caused by cervical spine
pathology such as bony protuberances,
osteophytes, or by soft tissue swelling due to
hematomas, infection, or tumor in the anterior
portion of the cervical spine.
Special Tests -5Adson: To perform this test, take the patient’s radial pulse at
the wrist. As you continue to feel the pulse, abduct, extend
and externally rotate his arm. Then istruct him/her to take a
deep breath and to turn his/her head toward the arm being
tested. If there is compression of the subclavian artrey, you
will feel a marked diminution or absence of the radial pulse,
then the test is positive.
This test is used to determine the state of the subclavian artery,
which may be compressed by an extra cervical rib or by
tightened scalenus anticus and scalenus medius muscles,
which can compress the artery where it passes between
them on its way to the upper extremity.
Special Tests -6Spurling: To perform this test, instruct the paient to extend,
lateral flex and rotate his/her head. Then, press down upon
the the top of the patient’s head while he is either sitting or
lying down, if there is an increase in pain in the neck and/or
arm(s), then the test is considered to be positive.
A narrowing of the neural foramen, pressure on the facet joints
or muscle spasm can cause increased pain. In addition, this
test may reproduce pain referred to the upper extremity
from the cervical helping to locate the neurological level of
any existing pathology.
Special Tests -7Slump: This test is a progressive series of maneuvers
designed to place the sciatic nerve roots under
increasing tension. The patient sitting on the
examining table, flexes the cervical, thoracic and
lumbar spine, extends one of the knees and
dorsifelexes the foot on the same side. If the patient
experiences pain in low-back and/or leg(s), the test
is positive.
THORACIC SPINE
INSPECTION-1
* The patient must be
undressed,
* Posture
* Supine, prone and
side-lying
INSPECTION-2
* Spina scapula  T3
* End of scapula  T7-9
* Medial border of the scapula and
spinous processes  5 sm.
* End of the ears, acromions and,
iliac crests must be horizontal
PALPATION and PRESSION
* PVM
* Facet joints
* Spinous processes
* Interspinous spaces
ROM-1
* Flexion
 20-45°
* Extension
 20-45°
* Lateral flexion 20-40°
* Rotation
 35-50°
ROM-2
* Sitting position,
* C7-T12: 3 sm., C7-S1 15 sm.
* Structural scoliosis does not
change in flexion
Neurologic Examination
The level of the lesion by key points
There is no key muscle
Beevor’s sign
Key Points
T2: KP: Apex of the axilla
T3: KP: Third intercostal space (mid-clavicular line)
T4: KP: Fourth intercostal space (nipple level, mid-clavicular line)
T5: KP: Fifth intercostal space (mid-clavicular line)
T6: KP: Sixth intercostal space (xiphoid level, mid-clavicular line)
T7: KP: Between T6 and T8 (mid-clavicular line)
T8: KP: Between T7 and T9 (mid-clavicular line)
T9: KP: Between T8 and T10 (mid-clavicular line)
T10: KP: Umblicus (mid-clavicular line)
T11: KP: Between T10 and T12 (mid-clavicular line)
T12: KP: Superior of the middle of the inguinal ligament (mid-clavicular
line)
Special tests
* Slump
* Passive scapular approximation
* First thoracal nerve stretching
Special tests - 2
Passive scapular approximation test: The
patient lies prone. The shoulders are
stretched backwards with the
approximation of scapulae. If there is
pain or pain worsening the test is
pozitive.
This test stretches the first thoracal spinal
nerve.
Special tests - 3
First thoracal nerve stretching test: The
patient abducts the shoulder to 90°, flexes
the elbow and holds the occipital region
of the head and the shoulder is forced to
extention. If there is pain or pain
worsening the test is pozitive.
This test stretches the first thoracal spinal
nerve.
Special tests - 4
Beevor's sign is the movement of the belly
button towards the head on flexing the neck.
It is caused by weakness of the lower
abdominal muscles.
Beevor’s sign is characteristic of spinal cord
injury at the T10 level. It has also been
described in amyotrophic lateral sclerosis
and facioscapulohumeral muscular
dystrophy.
LUMBAR SPINE
INSPECTION - 1
- Lordosis
- Scoliosis
- Swelling
- Deviation
- Muscle atrophy
INSPECTION - 2
- Muscle spasm
- Color changes
- Lipomas
- Abnormal hair
- Café au lait spots
- Postural changes
PALPATION-1
Bone – Joint:
- Spinous processes
- Interspinous spaces
- Facet joints
- İliac crests
- Coccyx
PALPATION-2
SOFT TISSUES
- Swelling
- PVM
- Ligaments
- Umblicus (L3-4)
- Sacral promontorium
PALPATION-3
VALLEIX POINTS:
1. Middle of the trochanter major ve ischial
tuberosity
2. Middle of the posteroir thigh
3. Middle of the popliteal fossa
4. Middle of the gastrocnemius muscle
5. Middle of the Achilles tendon
ROM
- Flexion
- Extension
- Lateral Flexion
- Rotations
- Circumduction
NEUROLOGIC EXAMINATION
- DTR
- Muscle testing
- Sensation
Neurologic examination
L1: KM: None, KP: inferior of the middle of the inguinal ligament.
L2: KM: iliopsoas, KP: midway of the KPs L1 and L3
L3: KM: quad. femoris, KP: medial femoral condyl, DTR: patella.
L4: KM: tibialis anterior, KP: medial malleolus
L5: KM: extensor hallucis longus, KP: third metatarsophalangeal
joint at the dorsum of the foot.
S1: KM: gastrocnemius-soleus, KP: lateral of the heel, DTR:
Achilles.
Special tests – 1Straight Leg Raising Test (SLRT): The patient lies on his
back (supine). The examiner raises the leg with the knee
extended straight. Normally, the angle between the leg and
the bench can reach 70° – 80° without any discomfort. If the
patient experiences pain before, the test is positive.
To differentiate between sciatic nerve stretching and
hamstring muscles tightness, lower the leg a few angle and
dorsiflex the foot in order to relax the hamstrings and to
stretch sciatic nerve. If the patient reexperiences pain along
the sciatic nerve, this is due to sciatic nerve stretching.
Special tests - 2
Contralateral SLRT: If there is low-back and/or
contralateral leg pain when the uninvolved leg is
raised the test is positive.
This test may be associated with a considerable disc
hernation or a space occupying lesion.
Special tests - 3
Kernig’ sign: The patient lies supine (flat on the
back), flexes his head with hands on the occipital
region. If the patient experiences neck pain and/or
pain along the vertebral column the test is positive.
This may be a sign of meningeal or spinal nerve roots
irritation.
Special tests - 4
Naffziger’s test: Pressure is applied on the jugular vein
of the patient lying on his/her back for 10 seconds.
When the face of the paient flushes he/she is requested
to cough. If he/she experiences low-back and/or leg
pain the test is positive.
Pressure on the jugular vein results in increased
cerebrospinal fluid pressure and may cause pain in the
case of a herniated disc.
Special tests - 5
Valsalva test: The patient takes a deep breath, holds
and attempts exhalation against a closed glottis and
closed mouth and nose.
If there is low-back and/or leg pain the test is
positive.
Valsalva test increases the intrathecal pressure.
Special tests - 6
Hoover test: This test determines whether the patient is
malingering when he states that he/she cannot raise his leg,
and should be performed in conjuction with straight leg
raising test. When a patient is genuinely trying to raise
his/her leg, he/she puts pressure on the calcaneus of his/her
opposite leg to gain leverage; you can feel downward
pressure on your hand. If there is no pressure the patient is
malingering.
Special Tests - 7
Pelvic Rock: The patient lying supine, the
examiner places hands on the iliac crests of
the patient with thumbs on the anterior
superior iliac spines, and palms on the iliac
tubercles. Then, forcibly compresses the
pelvis toward the midline of the body. If the
patient complains of pain around the sacroiliac
joint, there may be pathology in the joint
itself, such an infection or problem secondary
to trauma.
Special Tests - 8
Gaenslen’s sign: Have the patient lie supine on
the table and ask him to draw both legs onto
the chest. Then, shift the patient to the side of
the table so that one buttock extends over the
edge of the table while the other remains on it.
Allow the unsupported leg to drop over the
edge, while the opposite leg remains flexed.
Complaints of subsequent pain in the area of
the sacroiliac joint give another indication of
pathology in that area.
Special Tests - 9
Femoral nerve stretch: The patient
lying prone, the examiner fully
flexes the knee and extends the hip.
If the patient experiences pain in
the anterior area of the thigh, the
test is positive.
Special Tests - 10
Slump: This test is a progressive series of
maneuvers designed to place the sciatic nerve
roots under increasing tension. The patient
sitting on the examining table, flexes the
cervical, thoracic and lumbar spine, extends
one of the knees and dorsiflexes the foot on the
same side. If the patient experiences pain in
low-back and/or leg(s), the test is positive.