Musculoskeletal (Spine) Flashcards
What are you looking for on inspection of the spine?
Expose patient suitably - underwear and bra
Inspect from all sides
Skin - cafe-au-lait (+/- neurofibromatosis), sacral dimple, scars
Cervical - deformity, scars, asymmetry
Lumbar - kyphosis, scoliosis
What are you looking for on palpation of the spine?
Vertebrae and paraspinal muscles for tenderness
Cervical spine and neck posteriorly in the midline, laterally and anteriorly (incl brief thyroid exam)
Supraclavicular fossa - masses ie LNs, tumours
Thoracolumbar and sacrum - spinous processes and muscles; palpable step at the lumbosacral junction may indicate spondylolisthesis (slipped vertebra)
Sacroiliac joint - tenderness in AS
How do you assess range of movement of the cervical spine?
Active - flexion (chin to sternum), extension; lateral flexion (normal = 45 degrees), lateral rotation (80 degrees) - prior two restricted in cervical spondylosis
Passive - perform same movements passively and cautiously if restrictions found whilst feeling for creptius
How do you assess the range of movement of the thoracic and lumbar spine?
Flexion - assessed by recording the distance of a patients fingers from the ground when bent over (<7cm) or lowest level person can reach ie mid-tibia
Extension - ask patient to arch back, normal range is 25 degrees thoracic/35 degrees lumbar - limited in disc prolapse/fracture
Lateral flexion - with patient standing and legs 30cm apart, measure the distance between fingertips and floor then get them to maximally flex sideways and remeasure; normal >10cm difference between measurements
Rotation - seat patient with arms folded across chest; ask to twist - 40 degrees is normal
What is a modified Schober’s test?
Used as a quantitative measure of flexion of lumbar spine
Mark 15 cm of lumbar spine measuring 10cm above and 5cm below PSIS with patient standing
Get patient to flex maximally and re-measure the distance between the marks - normal flexion with be an increase between the marks of at least 5cm
What else do you have to assess?
With patient slightly bent forward, lightly percuss the spine from neck root to sacrum
Tenderness indicates infection/fracture/neoplasia etc
Gait assessment
What special tests should be performed if vertebral disc prolapse suspected?
Straight leg raise - patient flat on couch, passive flexion of hip with extended leg - back or leg pain = positive finding; parasthesiae or pain in nerve root distribution suggests nerve root irritation - can also lower leg until pain disappears then dorsiflex the foot - if signs increase again = Lasegue’s sign
Bowstring test - straight leg raise, if pain felt, flex knee slightly and apply pressure in popliteal fossa stretching tibial nerve - radiating pain + parasthesiae suggests nerve root irritation
Femoral stretch test - prone and anterior thigh fixed to couch, flex each knee in turn
- skin irritation over anterior compartment by irritating L2-4
What special tests should be performed if ankylosing spondylitis is suspected?
Assess chest expansion at the level of the 4th intercostal space (3-5cm = normal, reduction is positive)
How do you complete the examination?
Neurovascular assessment of upper and lower limbs
Lower back pain - abdo exam for masses, PR exam for cauda equina, hip exam for OA
Neck pain - shoulder examination
