MSK Exam - The Spine

What is the central supporting structure of the trunk and back?

spine

What makes up the spine?

cervical, thoracic, and lumbar spine

Describe the convexity and concavity of the spine.

Cervical & lumbar spine = concave

Thoracic and sacrococcygeal = convex

How many vertebrae make up the vertebral column?

24 vertebrae on top of sacrum and coccyx

Anterior structures & function

vertebral body, supports weight-bearing

Posterior structures & function

vertebral arch, encloses the spinal cord

What projects posteriorly at the midline?

spinous process

What is the spinous process an attachment site for?

muscles

Articular surfaces

superior and inferior processes, where joints articulate together

Articular facets

inferior articular surfaces at the junction of pedicles and laminae

Vertebral foramen

encloses the spinal cord, allowing for a channel for the cord and nerve roots

Transverse foramen

seen in cervical vertebrae, allows for the passage of the vertebral artery

Intervertebral discs

cushions movement between the vertebrae and allow the vertebral column to curve, flex, and bend

What is prominent at the base of the neck?

C7/T1

What vertebral level is the angle of the scapula?

T7

What vertebral level are the iliac crests?

L4

What vertebral level is the line across the PSIS?

S2

Nerve root sections

- C1-C7 vertebrae

- T1-T12 vertebrae

- L1-S1 vertebrae

What are the C1-C8 nerve roots named for?

vertebrae below

What are the T1-T12 nerve roots named for?

vertebrae above

What are the L1-S1 vertebrae named for?

vertebrae above

What are the muscle groups in the spine?

- trapezius

- latissimus dorsi

- splenus capitus

- splnus cervicis

- sacrospinalis

- psoas

Where does the psoas attach to, and what is its function?

Attaches to the anterior surface of the vertebrae, assists with flexion

What criteria do you want to consider in a case of neck pain after trauma?

- NEXUS criteria

- Canadian C-spine criteria

NEXUS criteria

alert, no midline c-spine tenderness, no focal neurologic deficits, no intoxication, no painful distracting injury

Canadian C-Spine criteria

age, mechanism of injury, ROM testing, testing of neck rotation

What might be signs of radiculopathy in a case of neck pain?

numbness, tingling, paresthesia, weakness

HPI components to consider for a complaint of back pain.

- trauma

- midline or off midline

- radiation to the buttock or leg

- numbness, weakness, tingling, or paresthesia

- bowel or bladder dysfunction

- psychosocial factors (anxiety, depression, work stress)

Red flags for low back pain from underlying systemic disease

- age <20 years or >50 years

- Hx of cancer

- unexplained weight loss, fever

- pain >1 mo or not responding to treatment

- pain at night or present at rest

- Hx of IVDA or immunosuppression

- active HIV infection or active infection

- long-term steroid use

- saddle anesthesia, bladder or bowel incontinence

- neurologic symptoms or progressive neurologic deficit

- lower extremity weakness

- Hx of osteoporosis

- recent spinal procedures

- progressive gait disturbance

What should you inspect during a spine exam?

- posture

- position of head and trunk

- erect position of head, neck, and back

- coordinated, smooth movement

- ease of gait

- spinal curvatures

- skin findings

What is Adam's forward bend test a screening for?

scoliosis

What might Cafe-au-lait spots suggest?

neurofibromatosis

What might hair tufts/hemangiomas suggest?

spina bifida occulta

What is needed for a complete inspection of the back?

full exposure of the entire back

What should you inspect on the posterior back?

- spinous processes

- paravertebral muscles

- iliac crests (level of L4)

- posterior superior iliac spines (dimples)

- curvature, alignment, skin markings, masses

How should you inspect the curvature of the cervical, thoracic, and lumbar spine?

from the SIDE

What more general structures should you inspect on the back?

- skin

- spinal column

- alignment of shoulders, iliac crests, and gluteal folds

Where should the spinal column be straight?

from C7 to the gluteal cleft

What should you palpate for during a spine exam?

- vertebral spinous process

- facet joints in the cervical spine

- step-offs or deformities

- sacroiliac joint

- paravertebral muscles

- sciatic nerve

How do you palpate facet joints in the cervical spine?

1- 2 cm lateral to the spinous process of C2-C7, deep to the trapezius (not always palpable)

How do you palpate for step-offs or deformities?

prominent or recessed spinous process in the lumbar region

True or False: The sciatic nerve is often palpable.

False, it is NOT often palpable

Where does the sciatic nerve lie?

midway between the greater trochanter and the ischial tuberosity

What is the most mobile portion of the spine?

neck

Where do flexion and extension of the neck primarily occur?

between the skull and C1

Where does the rotation of the neck primarily occur?

C1-C2

Where does the lateral bending of the neck occur?

C2-C7

What is the normal ROM for neck flexion?

45 degrees

What is the normal ROM for neck extension?

55 degrees

What is the normal ROM for neck rotation?

70 degrees

What is the normal ROM for neck lateral bending?

40 degrees

How should flexion of the spinal column appear?

smooth and symmetric

What happens to lumbar concavity during spinal column flexion?

it flattens out

What is the normal ROM for spinal column flexion?

75 degrees

What is the normal ROM for spinal column extension?

0-30 degrees

How do you assess ROM for spinal column extension?

Support the patient by holding your hand on the posterior iliac spine with your fingers pointing towards the midline

What is the normal ROM for spinal column rotation?

30 degrees

How do you assess ROM for spinal column rotation?

Stabilize the patient's pelvis by placing one hand on the patient's hip and the other on the opposite shoulder. Pull the shoulder anteriorly and the hip posteriorly.

What is the normal ROM for spinal column lateral bend?

35 degrees

How do you assess ROM for spinal column lateral bend?

Stabilize the pelvis by placing a hand on the patient's hip

Waddell Signs

Behavioral signs that assess for possible psychological contributions to the patient's back pain

What are the 5 categories of response for Waddell Signs?

- nonorganic tenderness

- stimulation tests

- distraction tests

- regional disturbances

- overreaction

What indicates that psychosocial factors might be influencing pain?

3 or more signs in Waddell categories

What does a straight leg raise assess for?

radicular pain ("sciatica")

How do you perform a straight leg raise?

Patient supine, raise the leg straightened, flexing at the hip. Assess degree of elevation of which pain occurs.

What is a positive straight leg raise test?

Reproduced pain radiating into the same leg below the knee, between 30 and 70 degrees

What is a positive crossed straight-leg raise sign?

increased pain when the healthy leg is raised

How do you perform a distracted straight leg raise?

The test is usually performed while the patient is seated on the edge of an examination table. While the patient is distracted, the examiner casually extends the patient's knee or raises their leg.

How would the patient react to a distracted straight leg raise if the nerve roots were compressed?

Sudden leg straightening will elicit a sharp, shooting pain down the leg, and the patient will usually lean back or reflexively complain

What does the heel/toe walk test?

strength of dorsiflexion and plantar flexion

C5 nerve root pain location

neck, lateral shoulder

C5 nerve root motor location

deltoid, biceps

C5 nerve root motor physical exam

strength of shoulder abduction and elbow flexion

C5 nerve root reflex

biceps reflex

C5 nerve root sensory area

lateral upper arm

C5 nerve root sensory physical exam

Assess for sensory deficit (numbness over the lateral upper arm)

C5 nerve root screening test

Spurling's test

C6 nerve root pain location

neck, lateral arm, thumb

C6 nerve root motor location

biceps, wrist extensors

C6 nerve root motor physical exam

strength of elbow flexion and wrist extension

C6 nerve root reflex

brachioradialis reflex

C6 nerve root sensory area

lateral forearm, thumb, index finger

C6 nerve root sensory physical exam

assess for sensory deficits (numbness over lateral forearm)

C6 nerve root screening test

Spurling's test

C7 nerve root pain location

neck, triceps area, down middle of hand

C7 nerve root motor location

triceps, wrist flexors, finger extension

C7 nerve root motor physical exam

strength of elbow extension, wrist flexion, and finger extension

C7 nerve root reflex

triceps reflex

C7 nerve root sensory area

posterior arm, dorsal forearm, middle finger

C7 nerve root sensory physical exam

assess for sensory deficit (middle finger)

C8 nerve root pain location

neck, medial arm, ulnar hand

C8 nerve root motor location

finger flexors, interossei, thenar muscles

C8 nerve root motor physical exam

strength of finger flexion

C8 nerve root sensory area

medial forearm, 4th and 5th fingers

C8 nerve root sensory physical exam

assess for sensory deficits (medial forearm, 4th and 5th fingers)

C8 nerve root screening tests

grip strength, Froment's sign, Spurling's test

T1 nerve root pain location

axilla, medial upper limb

T1 nerve root motor location

intrinsic hand muscles (interossei)

T1 nerve root motor physical exam

assess strength of finger abduction & atrophy of intrinsic muscles

T1 nerve root sensory area

medial upper arm