Text Book Reading

2015

January

PHYSICAL EXAMINATION THE

SPINE
Supervisor :
dr. Jainal Arifin, M.Kes, Sp.OT
Advisor :
dr. Mervin O. Jakarmilena
dr. Rico Alexander
dr. Zuwanda Then

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University
Makassar
2015

ANATOMY OF SPINE
GENERAL INFORMATION
33 Vertebrae:

7 Cervical (lordosis)
12 Thoracic (kyphosis)
5 Lumbar (lordosis)
5 Sacral fused (kyphosis)
4 Coccygeal (fused)

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

GENERAL
INFORMATION
Root exit spinal column
intervertebral foramen

via

C1-7 : exit above their vertebra

C8-L5 : exit below their vertebra
(C7 exit above C7 vertebra and C8
exit below C7 vertebra)
Medula spinalis end at L1 (Conus
Medullaris)
Lumbar and sacral nerve form
cauda equina in spinal canal before
exit

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

DENIS SPINE COLUMNS

Anterior :

of anterior body of
vertebra
of discus vertebralis
Anterior longitudinal
ligament

Middle :

of posterior body of
vertebra
of discus vertebralis
Posterior longitudinal
ligament

Posterior :

Pedicles
Facet joint
Lamina
Spinous process
Interspinous,
supraspinous ligament
Ligamentum Flavum

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.;

Review of Orthopaedics, 5th ed.

FACET JOINT
There are four facet joints
associated with each
vertebra.
A pair that face upward and
another pair that face
downward.
These interlock with the
adjacent vertebrae and
provide stability to the
spine.
The vertebrae are separated
by intervertebral discs which
act as cushions between the
bones.

Source: Review of Orthopaedics, 5th ed.

CERVICAL VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

CERVICAL VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

THORACAL VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

LUMBAL VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

SACRUM AND COCCYGEAL

VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

CORESPONDING STRUCTURE
OF VERTEBRA

Source: Netters Concise Orthopaedic Anatomy, 2nd ed.

SPINAL CORD

Source: Review of Orthopaedics, 5th ed.

CERVICAL EXAMINATION

INSPEKSI

SYMMETRY/
ASYMMETRY
DEFORMITY
TORTICOLIS
HEMATOMA

PALPATION
STEPS TWO

STEPS ONE
Tenderness
Tumor mass

Palpate the
lateral aspects
of the vertebra

STEPS
THREE

STEPS FOUR

Continue
palpation
into the
supraclavic
ular fossa

Examine the
anterior aspect of
the neck

MOVEMENT
STEPS ONE

STEPS TWO

STEPS THREE

Flexion
Ask the patient to bend
the head forward

Extension
Ask the patient to till
the head backward

Using a spatula in the

clenched teeth as a
pointer. Then ask the
patient to flex the head
forward. Normal range
= 80

STEPS FOUR

Ask the patient to

extend the head.
Normal range = 50
The total range in the
flexion and extension
planes should be
assessed. Normal
range = 130

STEPS
FIVE

STEPS SIX

Lateral flexion
Ask the patient to
tilt his head on to
his right shorulde

Laterral flexion
For accurancy, using a
spatula as a pointer.
Normal range = 45

STEPS
SEVEN

If lateral flexion cannot

be carried out without
forward flexion, this is
indicative of pathology
involving the atlantoaxial
and atlanto-occipital
joints.

STEPS EIGHT

Rotation
Ask to patient to look
over the shoulder.

STEPS
NINE

Rotation
Again a spatula use a
pointer. Normal
range = 80

SPECIAL TEST

THORACAL PHYSICAL
EXAMINATION

INSPECTION

PALPATION

PERCUSSION

MOVEMENT

MOVEMENT FLEXION
Schobers method : a
10 cm length of
lumbar spine is used
as a base, where a
15 cm length of
spine is employed.
Begin by positioning
a tape measure with
the 10 cm mark level
with the dimples of
Venus (which mark
the posterior
superior iliac spines).

MOVEMENT FLEXION
Anchor the top of
the tape with a
finger and ask the
patient to flex as
far forward as he
can.

MOVEMENT FLEXION
Flexion in the
thoracic spine may
be measured with
the upper point 30
cm from the
previous zero
mark.

MOVEMENT EXTENTION
patient arches his
back, assisting him
by steadying the
pelvis and pulling
back on the
shoulder

MOVEMENT LATERAL FLEXION

measure the angle
formed between a
line drawn through
T1, S1 and the
vertical

MOVEMENT ROTATION
The patient should
be seated, and asked
to twist round to
each side. Rotation is
measured between
the plane of the
shoulders and the
pelvis. The normal
maximum range is
40 and is almost
entirely thoracic

SUSPECTED THORACIC CORD

COMPRESSION
Use a blunt object
such as the handle of
a tendon hammer to
stroke the skin in each
paraumbilical skin
quadrant.
Failure of the
umbilicus to twitch in
the direction of the
stimulated quadrant
suggests cor
compression on that
side at the appropriate
level

SUSPECTED THORACIC MOTOR ROOT

DYSFUNCTION
Beevors sign
The patient places his
hands behind his
head, flex his knees,
and sit up
See the movement of
the umbilicus to one
side (and up or down)
suggests that the
abdominal muscles on
that side are
unopposed i.e. there
is weakness on the
opposite side

SUSPECTED ANKYLOSING SPONDYLITIS

Check the patients
chest expansion at
the level of the 4thn
interspace
Less than 2.5 cm is
regarded as highly
suggestive of
ankylosing
spondylitis

Lumbal Examination

LUMBAL PHYSICAL
EXAMINATION

INSPECTION

PALPATION

PERCUSSION

MOVEMENTS

NEUROLOGICAL EXAMINATION
(SENSORIC)

SENSORIC EXAMINATION

LIGHT TOUCH SENSATION

0 Absent
1 Impaired
2 Normal
NT Not testable

All sensory testing is carried out with the patients eyes closed.
For screening purposes, light touch can be tested by lightly stroking the
patients skin with a soft object, such as a small paintbrush, a cotton wisp or
a tissue.
Normal sensation is established by comparison with sensation on the face, or
another area with normal sensation, if sensation of the face is affected.
Impaired sensation is any sensation that differs from that on the normal area.
Source: The Orthopedic Physical Examination, 2nd edition

SHARP-DULL DISCRIMINATION
Used to confirm the results of a light touch examination.
In this case, the patient is asked to identify whether the area being examined
is being touched with the sharp or dull end of a safety pin.
In an area of diminished sensation, the patient has difficulty distinguishing
between sharp and dull.

Source: The Orthopedic Physical Examination, 2nd edition

TEMPERATURE SENSATION
Ask the patient to distinguish between warm
and cold
With the eyes closed, touch the skin with
glass tubes of hot and cold water.

Source: The Orthopedic Physical Examination, 2nd edition

PROPRIOCEPTIVE SENSATION
To assess proprioception, the patient is instructed to close his eyes and
the examiner grasps one of the patients fingers or toes.
The examiner then alternately flexes and extends the digit several
times, randomly stopping in flexion or extension.
The patient should be able to identify whether the digit ends the
maneuver in extension or flexion.

Source: The Orthopedic Physical Examination, 2nd edition

VIBRATORY SENSATION
Vibration sense can be tested using a tuning fork of 256 Hz over bony
prominences such as the humeral epicondyles or the radial styloid.
The examiner rests the base of the vibrating fork on the bony prominence
and asks the patient to report when the vibration stops.
The examiner then stops the vibration suddenly with the free hand.
Normally, the patient identifies the cessation of vibration quite readily.

Source: The Orthopedic Physical Examination, 2nd edition

NEUROLOGICAL EXAMINATION
(MOTORIC)

PHYSICAL EXAMINATION

MOTORIC EXAMINATION

SCORING
Total paralysis

Palpable or visible
contraction

Active movement,
gravity eleminated

Active movement,
against gravity

Active movement,
against some
resistance

Active movement,
against full resistance

Not testable

NT

NEUROLOGICAL EXAMINATION
(PHYSIOLOGICAL REFLEX)
PHYSICAL EXAMINATION

UPPER EXTREMITY

Biceps reflex

Brachioradialis reflex

Triceps reflex

LOWER EXTREMITY

Patellar tendon reflex

Achilles tendon reflex

Source: The Orthopedic Clinical Examination, 2nd edition

NEUROLOGICAL EXAMINATION
(PATHOLOGICAL REFLEX)

PHYSICAL EXAMINATION

UPPER EXTREMITY

Hoffman-Tromner Reflex

Source: AAOS Comprehensive Orthopaedics Review; Fundamental of Neurology

LOWER EXTREMITY

Babinsky Reflex

Oppenheim Reflex

Gordon Reflex
Source: Fundamental of Neurology

RECTAL EXAMINATION
The coccyx is palpable through a rectal
examination that is performed in combination
with the examination for sphincter tone and
sacral root defects, if necessary.
Performed in all patients who have sustained
Traumatic injury
Bowel or bladder dysfunction

Key element
Anal wink
Bulbocavernosus reflex

Source: AAOS Comprehensive Orthopaedics Review