Back History and Physical Exam
History
Inspection
- posture, position of head, signs of neck stiffness
- assess gait
Inspect C spine lordosis, thoracic kyphosis, lumbo lordosis
- scoliosis - can be brought out with patient bending forward
- can be compensation for leg length discrepancy - have patient sit down to check
Birthmarks, port-wine stains, hairy patches, and lipomas can overlie bony defects such as spina bifida.
Palpation
Spinous processes (C7 is prominent one on back).
- tenderness can suggest arthritis, fracture or disclocation (if prior trauma), underlying infection, or malignancy
- paravertebral muscles with patients prone - helps them relax)
Sacroiliac joint: can be caused by ankylosing spondylitis
Pain on percussion can be caused by osteoporosis, infection, or malignancy.
The sciatic nerve lies midway between the greater trochanter and the ischial tuberosity. Tenderness suggests herniated disc or mass pushing on the contributing roots.
Range of Motion
C spine
- flexion/extension
- rotation
- lateral flexion
Rest of spine
Flexion/extension: not range of motion, smoothness and symmetry, and lumbar curve. A persisting lumbar curve can be seen with muscle spasm or in ankylosing spondylitis.
- Schober's test measures movement of lumbar spine: mark 10 cm above dimples of Venus (lumbosacral junction), have patient try to touch toes, measure distance between marks - should have increased to 14-15 cm.
Rotation (have patient seated to aviod hip swivels): have the patient place their hands on their hips to better observe rotation.
Lateral bending
Special Tests
- spinal nerve root testing
- Spurling's maneuver - lateral neck flexion and compression can lead to pain in a dermatome, suggesting cervical nerve root impingement
- straight leg raising: passive leg flexion with knee extension: positive sign is pain down leg in dermatome distribution - L5 or S1 nerve root impingement
- femoral stretch (psoas sign): with person prone, bend knee at 90 degrees and extend leg - pain suggests L2, L3, L4 nerve root impingement
- Faber test: flexion, abduction, external rotation press on the knee and the contralateral hip. pain suggestions SI joint problems