Rural Emergency Medicine

The Spine (Vertebral Column) serves a number of purposes (protection, muscle and ligament attachment, haematopoiesis and so on) and consequently has a range of associated pathologies. Musculoskeletal examination of the spine focuses on determining diseases and disorders that specifically effect that system in relation to the spine.

One of the most common complaints associated with the spine is back pain. Other spinal related complaints include paraesthesia (a sensation of tingling, pricking, or numbness) or pain in the lower limb, loss of function (e.g. inability to bend over) saddle anaesthesia in the anus, perineum or genitals and many more.

Red Flags for Spinal Pathology
Some red flags for spinal pathology;
  • Presentation in patient's < age 20 or onset > age 50
  • Constant, progressive, non-mechanical pain
  • Weight loss
  • Inflammatory disorders (ankylosing spondylitis and related disorders)
  • Systemically unwell
  • Family History
  • Drug Abuse
  • Systemic Steroids
Basic Anatomy
An understanding of basic spinal and associated surface anatomy is important for investigation of musculoskeletal disorders. The spine consists of 33 vertebrae; 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal. The sacral and coccygeal vertebrae fuse to form the sacrum and coccyx respectively. The Vertebra Prominens (C7) can be easily felt due to it's long and prominent spinous process, and marks the end of the cervical vertebrae.

Note the normal thoracic and sacral kyphoses, and cervical and lumbar lordoses in the diagram below.

Adapted from Grays Anatomy & Wikipedia

Spinal Clinical Examination
Following the preforma outlined in an Introduction to Musculoskeletal Clinical Examinations, a spinal examination begins with an introduction and the correct positioning of the patient. The typical spinal examination should then proceed through the following steps;

General inspection

  • Look specifically at bony landmarks (assess vertebral levels)
  • Check for posture, deformity, symmetry, spasm, swelling, skin changes, scars and wasting
  • Note any abnormal kyphosis, lordosis or scoliosis

  • Check skin temperature
  • Palpate spine - spinous processes, interspinous ligaments, facet join
  • Palpate paravertebral muscles for bulk, spasm and tenderness
  • Assess full range of active movement (passive movement is difficult and probably should not be performed by medical students): note symmetry, restriction, pain or neurological symptoms.
Assess Function

Special Tests
  • Cervical spine - Further neurological examination of the Upper Limb
  • Thoracic spine - Assess for scoliosis
  • Lumbar spine - Straight leg raise, femoral nerve stretch, slump test, FABER test
The video below provides a demonstration of performing a musculoskeletal examination of the spine for medical students.

Other Clinical Exams
Cardiovascular | Respiratory | Gastrointestinal | Neurological | Musculoskeletal

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