Cervical spine Physical examination: Look Observe the

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The SpineHistory Physical Examination
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History physical examination

• Cervical spine
• Consist of 7 vertebra
• 8 nerves
• Give two plexuses
• Cervical plexus ( C1-C5) brachial
  plexus ( C5-T1)
• Phernic ( C3,C4,C5)
  mucocutanous n (C5-C7)
• Lesser occipital (C2)
  axillary n (C5-C6)
• Supraclaviclular ( C3,C4)
  median n (C5-T1)
• 
  
  radial N (C5-T1)
• 
  
  ulnar n (C8-T1)

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History physical examination

• Cervical spine
• History
• acute trauma
• History of Falling down , vehicle accident .
• Any patient unconious form after heard injury you
  should assumed it as cervical spine injury.
• ABC, WAIT FOR help , x ray frontal lateral

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History physical examination

• Cervical spine
• History
• PAIN - analysis of pain
• Acute ,sub acute ,chronic
• Onset ,duration , character , severity ,radiation
  ,reliving ,aggravating factor
• At end of day /at night , other joint affected
• Weakness in upper limb
• Paraesthesia

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History physical examination

• Cervical spine
• History
• Pain and difficulty turning the head and
  neck, examples are
• ? Disease of atlanto-occipital joints
  produces pain radiating to the occiput.
• ? Spondylosis of the middle and lower
  cervical spines causes pain radiating to the
  upper border of trapezius, interscapular region,
  and the arms.
• ? Irritation of the C6 C7 nerve roots can
  give rise to referred pain in the interscapular
  region, radial fingers, and thumb.
• ? Irritation of C8 can cause pain on the
  ulnar side of forearm, ring, and little fingers.

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History physical examination

• Cervical spine
• Physical examination
• Look
• Observe the posture of the head and neck and
  note any abnormality and deformity, e.g. loss of
  lordosis.
• Feel
• ? The midline spinous processes
• ? The paraspinal soft tissues
• ? The supraclavicular fossae for cervical
  ribs or enlarged lymph nodes
• ? The anterior neck structures including the
  thyroid

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• Move
• ? Assess active movements
• forward flexion?Put your chin on your chest
• Extension?look upwards at the ceiling as far back
  as you can
• Lateral flexion?Put your ear onto your shoulder
• Lateral rotation?Look over your right/left
  shoulder

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• ?occiput to wall test
• ? Gently perform passive movements if there are
  reduced active movements and see if the end of
  the range has a sudden or gradual resistance and
  whether it is pain or stiffness that restricts
  movements

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History physical examination

• Cervical spine
• Physical examination Cont. ( Neuro exam)

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History physical examination

• Thoracic spine( T1-T12)
• History
• ? Commonly, localized spinal pain, examples
  are
• Ankylosing spondylitis produces pain in the
  thoracolumbar region
• Acute thoracic spinal pain may be due to
  vertebral prolapse due to malignancy, or
  infection especially if there was systemic upset
  or fever is present
• ? Less commonly, symptoms of paraparesis
  including sensory loss, leg weakness, and loss of
  bladder or bowel control

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History physical examination

• Thoracic spine
• Physical examination
• Look
• With the patient standing, inspect posture
  from behind, the side and the front, noting any
  deformity, e.g. rib hump or abnormal curvature.
• Feel
• ? The midline spinous processes
• ? The paraspinal soft tissues
• ? If there is increased prominence of one or
  more spinous processes implying anterior
  wedge-shaped collapse of the vertebral body
  often related to osteoporosis.
• Move
• Ask the patient to sit with arms crossed, and
  to twist round and look at you.

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History physical examination

• Lumbar spine
• LUMBAR NERVES( L1-L5)
• SACRAL NERVES ( S1-S4)
• LUMBAR PELUXES ( L1-L4)
• illioingunal (L1) , iliohypogastric (L1) ,
  genitofemoral (L1-L2), Femoral (L2-L4)
• Obuturator (L2-L4)
• SACRA L PELUXES
• SCIATIC NERVE (L4 S3)
• 1- Common peroneal
• 2- Tibia

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History physical examination

• Lumbar spine
• SCITICA - PAIN extend from buttock ,
  poster-lateral of leg , lateral aspect of foot
• Common risk factor -
• 1-Herniated disc
• 2- pregnancy
• 3-osteoarthritis
• 4- wrong IM INJECTION

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History physical examination

• Lumbar spine
• History
• ? Low back pain is an extremely common
  complaint
• ? Sacroilitis produces pain that is referred
  down both legs to knees
• ? Consider abdominal and retroperitoneal
  pathology, e.g. abdominal aortic aneurysm,
  pancreatitis, peptic ulcer, renal pathologies.

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History physical examination

• Lumbar spine
• Red flag features for acute low back pain
• ? In History
• Age lt 20 yrs or gt 55 years
• Recent significant trauma (fracture)
• Pain
• Thoracic (dissecting aneurysm)
• Non-mechanical (infection/ tumor/pathological
  fracture)
• Fever ( infection)
• Difficult micturition
• Fecal incontinence
• Motor weakness
• Saddle anesthesia
• Sexual dysfunction
• Gait change ( cauda equina syndrome)
• Bilateral sciatica

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History physical examination

• Lumbar spine
• Red flag features for acute low back pain
• ? In Past medical History
• Cancer ( metastasis.)
• Previous steroid use (osteoporotic collapse)
• ? In Systemic review
• Weight loss/malaise without obvious cause
  (e.g. cancer)

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History physical examination

• Lumbar spine
• Physical examination
• Look
• Examine the patient standing. Look for
  obvious abnormality such as decreased/increased
  lordosis, obvious scoliosis soft tissue
  abnormalities such as a hairy patch or lipoma
  that overlie spina bifida.
• Feel
• Palpate the spinous processes and the
  paraspinal tissues. The L4/L5 interspinous space
  is palpable at the level of iliac crests.

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History physical examination

• Move
• ? Flexion ask the patient to try to touch
  his toes with his legs straight
• ? Extension ask the patient to straighten up
  and lean back as far as possible
• ? Lateral flexion ask the patient to reach
  down to each side touching the outside of the leg
  as far down as possible while keeping the legs
  straight

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History physical examination

• LUMBER SPINE
• Physical examination Cont. ( Neuro exam)

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• Lumbar spine
• Physical examination-Cont.
• Special tests
• Schobers test for forward flexion
• Root compression tests
• Straight leg raise
• Tibial nerve stretch test
• Femoral nerve stretch test
• Flip test
• Sacroiliac joints test

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History physical examination

• Lumbar spine
• Schobers test for forward flexion
• 1- Erect position.
• 2- Select 2 bony points,10cm apart and mark it.
• 3-Maximum flexion on lumbar with fix knee.
• 4-the two points should separate by at least a
  further 5cm.

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History physical examination

• Schobers test

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• Straight Leg raising test
• -knee straight,slowly lifted the leg.
• -note for any tightness and pain in the buttock
  (around 80-90 )
• -passive dorsiflexion,increase the pain.
• -bow-string sign bending the knee
  slightly,release the pain.then apply firm
  pressure behind lateral hamstring,pain will
  recur.
• -

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Investigations

• Hematological erythrocyte sedimentation rate,
  complete blood count
• Biochemical C-Reactive protein , Ca level , ALP
• Serological RF , ANA
• X- ray
• CT scan
• MRI
• Isotope bone scan
• Ultrasound