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Anatomy of the spine

Columna Vertebralis

5 regions, 33 bones
Regions
Cervical ( 7 vertebrae)
Thoracic ( 12 vertebrae)
Lumbar ( 5 vertebrae)
Sacral bone (5 fused =
Sacrum)
Coccygeal bone (4 fused =
coccyx)
The Vertebral Column
Vertebrae separated by
intervertebral discs
Intervertebral discs (anulus
fibrosus + nucleus pulposus)
The Vertebral Column
- Spinal Curvatures
concave and convex curves

Curvatures :
Kyphosis (cervical and
lumbar)
Lordosis (thoracic and
sacrum)
Scoliosis (abnormal)
Vertebra
Typical vertebra has :
Corpus vertebra
Arcus vertebra (lamina and pedicle)
Foramen vertebra
Processus spinosus (1)
Processus transversus (2)
Processus articularis superior (2)
Processus articularis superior(2)
Cervical Vertebrae
Thoracic and Lumbar Vertebrae

Modified from Fig. 7.18


Sacrum and Coccyx
Cervical Examination
INSPEKSI

Symmetry/ asymmetry
Deformity
Torticolis
Hematoma
PALPATION

STEPS ONE STEPS TWO

Tenderness Palpate the lateral


Tumor mass aspects of the
vertebra
STEPS THREE STEPS FOUR

Continue palpation into Examine the anterior


the supraclavicular fossa aspect of the neck
MOVEMENT

STEPS ONE STEPS TWO

Flexion Extension
Ask the patient to bend Ask the patient to till
the head forward the head backward
STEPS THREE STEPS FOUR

Using a spatula in the Ask the patient to


clenched teeth as a extend the head.
pointer. Then ask the Normal range = 50
patient to flex the head
forward. Normal range The total range in the flexion and extension
= 80 planes should be assessed. Normal range
= 130
STEPS FIVE STEPS SIX

Lateral flexion Laterral flexion


Ask the patient to tilt For accurancy, using a
his head on to his right spatula as a pointer.
shoulder Normal range = 45
STEPS SEVEN STEPS EIGHT

If lateral flexion cannot Rotation


be carried out without Ask to ptient to look
forward flexion, this is over the shoulder.
indicative of pathology
involving the
atlantoaxial and
atlanto-occipital joints.
STEPS NINE

Rotation
Again a spatula use a
pointer. Normal range
= 80
Thoracal Physical Examination
Inspection

Position :
Patient stand

Examination :
Assess the thoracic curvature
from side

Note if the curve is regular or if


it appears to be increased
Position :
Bend forward

Examination :
Access the flow of movement in the
spine, and whether the curvature
increases

Note either the range of flexion in the


thoracic spine is small
Position :
Stand upright and brace back the
shoulders to produce extension

Examination :
Assess the curvature of the
thoracic spine

Note the increase and


mobilization of the thoracic spine
Position :
Patient standing and look forward

Examination :
Check if there is a regular but fixed
kyphosis is found

Noted if there is fixed kyphosis the


causes may be Senile kyphosis,
Scheuermanns disease and
ankylosingspondylitis
Position :
Standing and look forward

Examination :
Check for an angular kyphosis, with a
gibbus or prominent vertebral spine

Note if there is angular kyphosis with


gibbus or prominent vertebral spine the
commonest causes are fracture,
tuberculosis of the spine, or a congenital
vertebral abnormality
Palpation

Position :
Patient sitting and bend forward

Examination :
Palpate and look for tenderness
higher in the spine at the thoracal
spine

Note if there is tenderness, indicates


there are vertebral body infections
Percussion

Position :
Patient bend forward

Examination :
Lightly percuss the spine in an orderly
progression from the root of the neck to
the sacrum

Results :
Note that significant pain is a feature of
tuberculous and other infections, trauma
(especially fractures) and neoplasms
Movement

Position :
Patient attempt to touch his toes

Examination :
Watch the spine closely for
smoothness of movement and any
areas of restriction

Note the importance of hip flexion


(A), which can account for apparent
motion in a rigid spine
Position :
Patient bend forward

Examination :
Note the distance between the finger
and the ground

This is an indication of the summation of


thoracic, lumbar and hip movement, it
does not distinguish between them, and
is under voluntary control
Position :
Patient flexes so that the fingertips
reach mid-tibia, or some other
appropriate level

Examination :
See the angle of range flexion. The
majority of normal patients can reach
the floor or within 7 cm from it

Actual maximum range flexion is


approximately 45 for thoracic
Position :
Patient stand straight, sitting up, and
leaning forward on the examination couch

Examination :
Flexion in the thoracic spine may be
measured with the upper point 30 cm
from the previous zero mark

Thoracic flexion is not great, and is


normally in the order of 3 cm. Note that
abdominal girth may increase after
osteoporotic fractures of the lumbar spine
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
Examination of the Vertebra Lumbal
History Taking

Physical Examination
History taking
1. Note the patients age and occupation: both
may be relevant.
2. Ask about the onset of the pain
3. Ask about any directly relevant previous
history
4. Ask about the site and nature of the pain
5. Ask about radiation of the pain
6. Ask about motor involvement
7. Make enquiries in the following areas
Inspection

Palpation

Percussion

Movements

Physical Examination
Inspection
Palpation
Percussion
Movements