Revisiting History and Examination of the Spine

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Revisiting History and Examination of the Spine

• Manoj Krishna
• Consultant Orthopedic Spinal Surgeon

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Spinal Causes of Back Pain

• Discogenic pain
• Facet arthritis
• Muscle strain
• Spondylo-listhesis
• Spinal Stenosis
• Fracture
• Discitis
• Vertebral Osteomyelitis

• Ankylosing Spondylitis
• Rheumatoid Arthritis
• Tumor mets, myeloma
• Osteoporosis,Osteomalacia
• Sickle Cell Disease

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Extra-spinal causes of back pain

• Renal calculus, UTI
• Duodenal Ulcer
• Abdominal Aneurysm
• Heart Disease
• Pancreatitis
• Retroperitoneal tumor
• Biliary colic
• Pelvic inflamation

• Ectopic
• Endometriosis
• Steroids- osteoporosis
• NSAID- peptic ulcer
• Hip disease
• SI joint problem
• Scapulo-thoracic pain
• Psychogenic

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Extraspinal causes of Sciatica

• INTRAPELVIC
• Tumors
• Psoas Haematoma
• Endometriosis
• Abscess
• Aneurysms
• INTRANEURAL
• Diabetes
• Sciatic nerve fibrosis

• EXTRPELVIC
• Gluteal artery aneurysm
• Pseudoaneurysms
• Tumor
• Piriformis syndrome
• Abscess
• Greater tuberosity avulsions

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History

• Ratio of back and radicular pain
• ADL restriction getting worse?
• ? Intermittent
• Psychosocial issues
• Sleep
• Cancer?
• Fever?
• Smoking?

• PAIN
• Location
• Onset- started by ?
• Duration
• Character
• Periodicity
• Increased by ?
• Relieved by ?
• Pain killers?

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History

• Work
• Benefits
• Litigation
• Alcohol
• Relationships

• PAST HISTORY
• What physio
• Which P/K
• Cancer
• Family history
• Psychogenic illness
• Surgery

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History- radicular symptoms

• Neurogenic/Vascular claudication
• Diffuse or focal
• Hyper-esthesia/burning
• Inc. by coughing?
• Lhermittes sign?
• Bladder dysfunction?

• Hot shower- feels normal?
• Relieving factors
• Carpal tunnel night s/s?
• Heaviness in legs
• Loss of balance
• Visual problems
• Parkinsons?

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Neck Exam

• Gait wide based?, spastic?
• ROM F- 45, E-55, Rot-70, Lat bend-40
• Spurling compression test
• Distraction test
• Adsons test Abd., ext rotate shoulder, rotate
  neck to same side, take and hold deep breath-
  check pulses.

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Neurological Exam

• ? Cord/ Nerve root/ Brachial Plexus/Peripheral
  nerve
• Tinel sign- median/ ulnar nerve, Phalen test
• Sensory testing sharp pin prick, 2-point
  discrimination
• Hoffman sign after flexing/extending neck
• Sensory level ?

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Neurological Exam

• Clonus/ Babinski reflex / Abdominal reflexes /
  Crossed Adductor response
• Myelopathy hand- 5th finger abd, rapid
  opening/closure of fingers
• Scapulo-humeral reflex lesion above C3
• Proprioception- tuning fork/ position sense
• Peri-anal pinprick sensation.

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Gait

• Waddling tight hamstrings- listhesis
• Hyperextends knee- weak quads
• Trendelenburg lurch- L5- gluteus medius
• Push pelvis forward- S1- weak gluteus maximus
• Short leg gait- chk. Limb lengths

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Schobers test

• 10 cm above line across dimples
• Measure increase in flexion
• 5cm increase is normal

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Motor exam

• Heel walking( L5), Toe walking( S1), Squat(
  L3/4)
• Sustained knee flexion- Hip flexor on one side(
  L1-3) and Abductor on other side( L5)
• Inversion of foot- L4
• Eversion of foot- S1
• Co-relate above with individual ms. testing

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SLR

• Active and pssive
• Hoovers test place hand under opp. Foot- should
  feel pressure as leg is raised
• Lasegue- inc by foot dorsiflexion
• Kernigs- inc by neck flexion
• Femoral Stretch test

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Exam

• Hips- flexion/ abduction/ rotation
• FABER- for SI Joint
• Active extension when prone- gluteus maximus
  function- S1
• PULSES- pedal and at groin/ Doppler

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Waddell signs

• 3 observations of abnormal pain behaviour
• Non-anatomic distribution, pain out of
  proportion to stimulus, exaggerated pain
  behaviour- grimacing, moaning, vocalizing.
• 4 tests skin roll, twist, head compression, flip
  tests.
• ve malingering, trying to convince doctor,
• ve- if 3 or more incongruencies.