- Low back pain affects 70-90% of people at some time in their lives
- 2nd most common reason for visits to a primary care physician
- 2nd most common cause of missed work
- Most common cause of disability in patients <45 yo and third leading cause of disability for >45 yo
What are some neurologic symptoms related to spinal nerve root(s) or cord compression?
What are the components of the musculoskeletal spine examination?
3. Range of motion
4. Neuromuscular exam: muscle testing, sensory testing, reflexes
5. Special tests
6. Examination of related areas: shoulder (cervical spine) and hip (lumbar spine)
What parts of the spine are most prone to disc herniation? Why?
Cervical -- increased motion
Lumbar -- increased weight bearing
Seperate the gray matter of the spinal cord into the three different sections and their functions.
Ventral horn: cell bodies of motor neurons
Lateral horn: cell bodies of autonomic neuons
Dorsal horn: sensory input
Is the ventral rami sensory or motor?
Both -- has fibers from both sensory and motor components.
A collection of muscle fibers innervated by the motor axons within each segmental nerve (root)
Area of skin innervated by the sensory axons within each segmental nerve (root)
A patient presents with flaccid paralysis of the right arm. No pain, paresthesias or sensory loss noted. Lab reveals polio virus infection. What is the target of the virus?
Ventral horn of spinal cord gray matter
Motor system is affected
Which dermatome supplies the thumb?
What about the ulnar side of the hand?
Ulnar hand: C8
Most common infection of the peripheral nervous system. Acute nerualgia confined to the dermatome distribution of a specific spinal or cranial sensory nerve root.
Herpes Zoster (shingles)
What are some anterior and posterior landmarks for palpation in the cervial spine exam?
- Hyoid bone: C3
- Thyroid cartilage: C4-5
- First cricoid ring: C6
- Carotid tubercle: C6
- Cervical spinous processes: C7 largest
- Facet joints
Manual muscle testing: rated 5 to 1
5: Normal strength -- complete ROM against gravity with maximal resistance (examiner cannot overcome)
4: Active movement against gravity and moderate resistance through full ROM (examiner can overcome)
3: Active movement through full range of motion against gravity (no resistance)
2: Active movement through full ROM with gravity eliminated (no resistance)
1: Flicker or trace of contraction, but no joint motion (no palpable muscle action)
0: No contraction palpated (complete paralysis)
What are some causes of muscle weakness?
- Muscle strain
- Pain/reflex inhibition
- Peripheral nerve injury
- Nerve root lesion (myotome)
- Upper motor neuron lesion
- Tendon pathology
- Psychologic overlay
How do you test myotome C5?
How do you test myotome C6?
Extensor carpi radialis--extension of wrist
How do you test myotome C7?
Triceps -- elbow extension
How do you test myotome C8?
Flexor digitorum profundus-- 3rd distal finger flexion
How do you test myotome T1?
Abductor digiti minimi-- little finger abduction
How do you test root level L2?
Iliopsoas -- hip flexion
How do you test root level L3?
Quadriceps -- Knee extension
How do you test root level L4?
Tibialis anterior--ankle dorsiflexion
How do you test root level L5?
Extensor hallicus longus--big toe extensor
How do you test root level S1?
What is the scale for reflex testing?
1: slight or less than normal (trace response, includes response only brought out with reinforcement)
2: lower half of normal range
3: upper half of normal range
4: enhanced and more than normal (including clonus)
What root levels does biceps reflex test? Brachioradialis? Triceps?
What root level does the Patellar reflex test? Hamstring? Achilles?
Passive anterior cervical flexion elicits "electric-like" sensation down the spine or extremities.
What does it imply?
Cervical spinal cord pathology
Reproduction of radicular symptoms with cervical spine extension, rotation, and lateral flexion.
What does it imply?
Spurling's neck compression test
Implies cervical nerve root pathology
Flick the patient's middle finger.
What is a positive test?
What does it imply?
Positive: flexion-adduction of ipsilateral thumb and index finger
Implies upper motor neuron process affecting cervical spine or brain