1. بسم الله الرحمن الرحيم
EXAMINATION
OF THE SPINE

2. SYMPTOMS Pain Sciatica Stiffness Deformity Numbness or paraesthesia
Urinary symptoms
Other

3. How to Start IPEEP INTRODUCE. PERMISSION. EXPLANTION. EXPOSURE.
POSITION.

4. The Apley System All joint examinations follow this system: Look Feel
Move : Active then Passive
Special Tests
Radiograpgy.

5. Patient in standing

8. INSPECTION BONE CONTURES. SOFT TISSUE CONTOURES.
COLOUR AND TEXTURE OF THE SKIN.
SCARS OR SINUSES.

15. PALPATION SKIN TEMPERATURE. BONE CONTOURS. SOFT TISSUES CONTOURS:
Palpate swellings
LOCAL TENDERNESS.

17. MOVEMENTS Spinal joints : FLEXION . EXTENSION. LATERAL FLEXION.
ROTATION.
PAIN ON MOVEMENT.
MUSCLE SPASM.

18. MOVEMENTS Costo-vertebral joints Ranged indicated by chest expansion.
Sacroiliac joints
Pain on movement imparted by lateral compression of pelvis.

19. FLEXION .
Instruct the patient to stretch his fingers towards hIs toes, keepIng the knees straight.
It is important to Judge what proportion of the movement occurs at the spine and how much IS contrIbuted by hIp flexion Some patients can almost reach their toes, despite a stiff back,
simply by flexing unusually far at the hips. (Normally the hamstrings limit hip flexion to about 90 degrees when the knees are straight.)
The range may be expressed as a percentage of the normal,. or
as the distance by which the fingers fall to reach the floor.

20. Apparent or false flexion
Normal flexion of lumbar spine
due entirely to movement at the hips,
the hamstrings being unusually lax. In estimating
trunk flexion it is important to judge how much of the movement occurs at the
spinal joints and how much at the hips.

23. EXTENSION
Instruct the patient to arch the spine backwards, lookIng up at the ceiling.
Judge the range and express approximately as a percentage of
the normal.

24. Lateral flexion Instruct the patient to side each hand In
turn down the lateral side of the corresponding thigh. Observe the
range.

26. Rotation: With the feet fixed, the patient rotates the shoulders
towards each side in turn. Note the range of spinal rotation as distinct
from that which occurs at the knees and hips.

27. Examination of the patient in recumbent

28. Palpation of the iliac fossa.
Examine specifically for abcess.

29. Palpation of the iliac fossae and groins is an essential step in the
It should be remembered
that a 'psoas' abscess originating from a tuberculous lesion of the
lumbar spine first becomes palpable deep in the iliac fossa. Such an
abscess is felt most easily by pressing the flat palmar surface of the hand
and fingers against the flat inner aspect of the iliac bone

30. Signs with patient lying face downwards
Bony outlines
Tenderness
Sensations and Power
Femoral stretch test

31. Femoral stretch test Looking for femoral nerve root irritation L2-4
Patient prone, ant thigh fixed to couch, flex each knee
Pain felt in anterior compartment of the thigh
Aggravated further by extension of hip

33. NEUROLOGICAL STATE OF LOWER LIMB
Straight leg rasing test. Muscular system. Sensory sysytem. Reflexes.

34. Signs with patient lying on his back
Straight leg raising test (sciatic stretch)

36. Straight leg raising test
Holding the knee straight, lift each lower
limb in turn to determine the range of pain-free movement (normal
= 90 degrees; often more in women)
When associated with
clearly defined sciatica (and in the absence of gross disease of the hip),
marked Impairment of straight leg raising by pain suggests mechanical
Interference wIth one or more of the roots of the sciatic nerve.
The
pain is easily explained.
Even a normal sciatic nerve is tautened by
straight leg raising, though not to the point of causing pain by
dragging on the meningeal sheath that encloses the nerve root.

37. NORMALLY UP TO 90 DEGREE

41. Cutaneous distribution of nerve roots

42. Circulation in the limbs
Femoral artery pulsation
Popliteal artery pulsation
Dorsalis and posterior tibial artery pulsation
Rectal examination

43. Muscular system
Examine the muscles for wasting, hypertrophy, and fasciculation. Note the tone.
and test the power ,
comparing it with its counterpart in the opposite 11mb.
Circumiferential measurement is a reliable method of comparing
(calf muscles and thigh, the girth being measured at the widest part or equator

44. Muscle Power Testing MRC Scale
0 Total paralysis
1 Barely detectable contracture
2 Not enough to act against gravity
3 Strong enough to act against gravity
4 Still stronger but less than normal
5 Full power

46. SENSORY SYSTEM For touch , pin prick. Deep stimuli . Joint position.
Vibration.
Heat and cold examination

47. SWEATING. Feel the digit if it is moist , or dry.
Sweating depend upon intact sudomotor nerve fibers.

48. .
REFLEXES

49. The patellar reflex is dependent mainly on L.4 nerve

50. Testing the calcaneal reflex (mainly S. I nerve),

51. Examination of potential extrinsic sources of neck symptoms.
Examination should include. Abdomen, pelvis, rectal examination, lower limbs Peripheral vascular system.

52. Sometimes there are no local symptoms to indicate that the spine is the seat of the disorder,
Pain referred entirely to the buttock or to the lower 11mb.
often complain only of pain 'in the hip' or 'in the leg' when true source of the trouble is the lumbar spine.
Conversely, the symptoms may suggest a spinal lesion when in fact they arise from abdomen, pelvis, or lower limb, or from occlusion of artery or a leaking aortic aneurysm.

53. General examinations

54. Imaging Plain x-rays Computed tomography (with mylography) MR imaging
AP and lateral views
Oblique views
PA view of S.I. Joint
Computed tomography (with mylography)
MR imaging
Radioisotope scanning
Discography and facet joint arthrography

59. CLASSIFICATION OF DISORDERS OF THE TRUNK AND SPINE

60. CONGENIT AL ABNORMALITIES
Lumbar and sacral variations
Hemivertebra
Spina bifida

61. DEFORMITIES
Scoliosis
Kyphosis
Lordosis

62. INFECTIONS OF BONE Tuberculosis of the thoracic or lumbar spine
Pyogenic infection of the thoracic or lumbar spine

63. ARTHRITIS OF THE SPINAL JOINTS
Rheumatoid arthritis
Osteoarthritis
Ankylosing spondylitis

64. OSTEOCHONDRITIS Scheuermann's vertebral osteochondritis
Calve's vertebral osteochondritis

65. MECHANICAL DERANGEMENTS
Prolapsed lumbar intervertebral disc
Acute lumbago
Spondylolysis
Spondy lolisthesis
Spinal stenosis

66. TUMOURS Tumours in relation to the cord, or nerve roots
Other tumours of the trunk

67. CHRONIC STRAINS
Chronic lower lumbar ligamentous strain
Coccydynia

68. MISCELLANEOUS
Fibrositis
Senile osteoporosis

69. DISORDERS OF THE SACRO- ILIAC JOINTS
Tuberculosis of a sacro-iliac joint
Ankylosing spondylitis
Other forms of arthritis
Sacro-iliac ligamentous strain