Exam - Back and Neck

Exam

Inspection

·        Look at belt line: is the pelvis horizontal.

·        Scoliosis:

o  If postural (eg do to a short leg) will correct when sitting down.

o  If pathological will hump to one side when they bend forward

·        Dominant hand will usually have a lower shoulder (“Which hand do you sign your name with?”)

·        Check shape, scars, lumps, muscles spasms, etc

Neck

·        Examination: Look while sitting 

·        Feel. Place forearm against shoulder and fingers on forehead to stop them tensing when you push on the spine. Feel down cervical spine

·        Test movement actively. Extension, flexion and lateral flexion normally 45º. Left and right rotation normally 70º. If you need to measure, then measure from the sternal notch to the chin in each position

·        If neck pain, check neurology in arms

Thoracolumbar Spine and Sacroiliac Joints

·         Look for deformity – inspect from both back and sides. Look for scoliosis, eg from trauma, developmental abnormalities, vertebral body disease (eg rickets, Tb) or muscle abnormalities (eg polio)

·        Feel each vertebral body for tenderness and palpate for muscle spasm

·        Gently tap spine with closed fist: severe localised tenderness suggest infection/tumour/trauma ® do x-ray

·        Movement:

o   Flexion (touch toes), extension, lateral bending (slide hand down side of leg as far as possible without bending forward)

o   Rotation: sit on stool (fixes pelvis) and rotate each direction 

o   Schober‟s Test: for lumbar flexion. Make a midline mark at the level of the posterior iliac spine (about L5). Make another mark 5cm blow and 10 cm above the first mark. Ask the patient to touch their toes. An increase of < 5cm between the upper and lower marks Þ limitation of flexion 

o   Lasegue‟s Sign for lumbar disk prolapse: passive lifting of straight leg is limited by pain as Sciatic nerve is stretched ® root pain

o   Palpate sacroiliac joints while they lie on their stomach

·        Special tests:

o   Heel/toe walking, squatting may reveal weakness

o   Measure limb girth for wasting

o   Nerve tension tests: straight leg raising, sciatic stretch, femoral stretch

·        Always test legs:

o   Neuro: sciatic pain, sensation, power, reflexes

o   Pulses

·        Abdominal: Is this a bleeding AAA?  Pancreatitis radiating to the upper back?

Xray Interpretation (ABCS)

·        Alignment: anterior and posterior lines should be smooth curves

·        Bones: Assess each vertebrae – trace each round body. Processes and facet joint may be obscured. Look for osteophytes

·        Cartilage and joints: discs should be similar and even. Facet joint dislocation only occurs in association with severe damage to vertebrae

·        Soft tissue: disruption of shadows

·        Non-traumatic injuries very rarely have positive findings on plain X-ray