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Comprehensive Spine Examination — Transcript

by Dr. Vinay Kumar Singh · 9,266 words · 1,618 segments · language en · Watch on YouTube

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0:04hello viewers today i'm going to
0:06demonstrate you how to do a thorough
0:08spine examination
0:10so it part of this video it will cover
0:12neurological assessment of
0:14cervical and lumbar spine it will cover
0:17some common pathologies such as
0:19lumbar disc prolapse cervical
0:21spondylitis
0:23ankylosing spondylitis cervical
0:26myelopathy
0:27scoliosis and common spinal problems
0:30that we
0:32deal in day-to-day activities so after
0:34this video i am confident that you will
0:36be
0:37able to do a thorough examination and we
0:39will be able
0:40to start a proper treatment
0:44now as i said in the other videos which
0:47are my examination videos
0:49a thorough history is extremely
0:50important in order
0:52to do a proper examination so
0:56as with any examination you will start
0:57with some demographics such as you know
0:59age name
1:00sex and what is the occupation of the
1:02patient
1:04now once you have taken the demographic
1:05details uh the most common
1:08reason the patient will present to you
1:09is the pain so if
1:11in case of lumbar spine or
1:14spinal examination i think it's
1:16extremely important that we
1:19deal or address pain thoroughly in the
1:21history
1:22so we want to talk about the site we
1:24want to talk about the severity
1:27we want to talk about whether it's in
1:29the spine only whether it's radiating
1:30down to the legs or in the hands
1:32what are the aggravation factors what
1:34are the relieving factors
1:36is pain bad enough that it disturbs the
1:38sleep of the patient is patient taking
1:40any painkillers
1:41if patient is taking painkillers so what
1:43painkillers the patient is taking
1:45is it affecting the quality of life like
1:48day-to-day activities
1:49is it disturbing the sleep is pain
1:51associated
1:53with some claudication like symptoms
1:55that patient is walking and feels
1:57heaviness in the leg and has to stop
1:59after certain time
2:00and that can indicate towards spinal
2:03stenosis
2:04now the other thing that you want to
2:07deal into is a spinal problem may
2:09present with neurological issues such as
2:10weakness
2:11so we'll talk about if you inquire about
2:14weakness whether the
2:15patient is experiencing any weakness in
2:17upper limbs in the hands or in the lower
2:19limbs
2:20and once you have uh taken bit of the
2:23history
2:23we will confirm that in our examination
2:26finding
2:27now bladder and bowel symptoms
2:29especially
2:30cases of caudaequina which is an
2:32emergency
2:33whether patient is experiencing any
2:34bladder and bowel symptoms
2:36is also important any history of trauma
2:40trauma is probably one of the commonest
2:42reason that patient will present you in
2:44a clinic
2:45so take the history of trauma whether
2:48patient has lifted anything heavy
2:50after which she is experiencing or she
2:52is experiencing pain that could indicate
2:54towards cervical or columbus prolapse
2:58now the other uncommon causes are like
3:00infective
3:01causes are quite common in developing
3:03countries so history of
3:05fever history of loss of weight history
3:08of temperature
3:09is also important now in a daily patient
3:13loss of weight and pain
3:16getting worse you should think of a
3:19possible
3:21tumor in elderly patients
3:24so these are the common things that you
3:26should inquire i think one
3:27negative history that i always take in
3:29my spine examination
3:31is that whether the patient is having
3:33any dysuria or any imageria
3:36because a lot of times i have seen
3:37patients who have
3:39got any renal stones they end up
3:43in our spinal clinic so once you have
3:46taken the thorough history
3:48then you can move on to the next part of
3:51the examination
3:52once you have taken a thorough history
3:54then you move on to the examination
3:57for any examination it is extremely
3:58important that you have got
4:01appropriate exposure so in terms of
4:04exposure
4:05for a man i think he can wear shorts so
4:08that you have access to the head you
4:10have access to the whole spine
4:11and you can have access to the feet as
4:13well because
4:15sometimes deformities of feet can also
4:18manifest in spine for females i think if
4:22they can have their undergarments on
4:24that will be more than enough so once
4:26you have got exposure
4:28you move on to your next section of
4:30inspection
4:32so the first thing that i look in a
4:34patient when i'm examining
4:35spine is what is coronal balance and
4:38what is the sagittal balance
4:40so a coronal balance is when you're
4:42looking a patient
4:44directly from the front so if i'm the
4:46patient i want you want to
4:48see whether my shoulders are at the same
4:49level or not
4:51occasionally in cases of scoliosis
4:54where there has not been adequate
4:57compensation
4:58or in cases with this relapse you will
5:00see
5:02sometimes a poor coronal balance in
5:04which one shoulder will be
5:06higher and one shoulder will be lower
5:08that can indicate towards scoliosis
5:11if this is my position and my left
5:14shoulder right shoulder is at a higher
5:15level
5:16then the left shoulder occasionally if i
5:17have a disc on this side
5:19i will try to offload that disc and you
5:21can have poor
5:23coronal balance as well when you talk
5:25about sagittal balance
5:26you look the patient from the side and
5:28see whether the head is
5:30right in this bang in the center or not
5:32so if
5:33you see a lot of elderly patients who
5:35have got degenerative scoliosis
5:37they walk like this so the head is not
5:40in the center so this is a positive
5:41balance
5:42and this is a negative sagittal balance
5:45so you will
5:46see if it's an early stage the patients
5:50in order to keep their head on the in
5:52the center
5:53they will bend the knees so they will
5:55sometimes walk like this
5:57as soon as you make their knee straight
6:00they will become like this so this
6:01is positive sagittal balance so look for
6:04coronal balance
6:05and sagittal balance then we move on to
6:07inspection
6:08once you have assessed your coronal and
6:10sagittal balance you move on to the look
6:12part so looking
6:14at the skin first look for any obvious
6:16redness any obvious
6:19scars whether they are surgical scars or
6:21non-surgical scars that are seen
6:24you look for any obvious
6:27swelling or bruising in case of traumas
6:29if you notice swelling bruising or
6:31fullness
6:32and that can indicate towards this
6:33potential site of
6:35trauma or potential level of injury then
6:38again once you can look for any obvious
6:40other swellings which are seen
6:43then look for spinal stigmata such as a
6:46nevers or tuft of hair
6:47lower down you look for any cafe delay
6:50spots which are present which can be
6:52suggestive of neurofibroma
6:56and you can also look for the hairline
6:59so when you look at the hairline if it's
7:00a low hair line and
7:02there is an associated scapular problem
7:05then it can have you can think of
7:07syndrome such as hypophyll syndrome so
7:09these you just do a rough screening
7:11in look and once you have assessed the
7:14skin you move on to the muscle part so
7:16you look for any
7:17obvious wasting of the muscles where
7:19paraspinal muscles or muscles
7:21across the upper part of the chest or
7:23lower part but
7:24para spinal muscle wasting or opposite
7:27is paraspinal muscle
7:28prominence which can be seen if somebody
7:31has got lumbar disc prolapse or he or
7:33she is in pain you will see
7:34the paraspinal muscle becomes extremely
7:36prominent so look for any as
7:39any wasting or any muscle prominence
7:42once you have assessed this then i
7:43assess for any of this deformity so
7:45deformity
7:46though two common deformities are
7:47kyphosis scoliosis
7:49or a mixture of them called
7:51hyposcoliosis so
7:52for scoliosis kyphosis you will look
7:55from the side
7:56and assess if there is any excessive
8:00prominence or excessive kyphosis in the
8:03thoracic region
8:04when you look from the back you look for
8:06any obvious
8:08scoliosis which can be in form of
8:11deviation of this midline
8:13in form of rib humps or in form of
8:15pelvic asymmetry
8:17so assess this sometimes you can if you
8:21see any
8:21visible step that can be seen
8:24or level of the scapula and
8:28level of the psis as well so if somebody
8:30has got scoliosis and it's not
8:32compensated then you can have asymmetry
8:34of psis
8:36as well so once you have assessed the
8:38spine don't
8:40forget to assess the feet so always when
8:42you are looking
8:43for any deformities always look for
8:46deformities of the feet whether there is
8:47any caves deformity or chemovirus
8:49deformity
8:50which is commonly seen in spinal
8:53pathologies such as tethered cord
8:55or any issues um which
8:58can affect um the spinal cord at an
9:01upper level so do
9:02assess your feet your your your
9:05inspection is not complete unless
9:07you have assessed the feet so once you
9:10have
9:10done your look part of it then you come
9:13on
9:14to the field part or that is the
9:15palpation so it depends upon
9:17which reason is affected but all i do is
9:20all i used to is just i look at the
9:22patient's face
9:24and i just palpate in the midline
9:28right from the top going onto the bottom
9:30to see where is the pain
9:32and depending upon where the pain is you
9:35go for superficial
9:36palpation and you can do also just
9:38gentle
9:41thrust gentle tapping and if
9:44somebody and always look at the
9:46patient's face you can you will be able
9:48to localize
9:49the site of the issue there in the books
9:51you talk about rotational
9:54testing but i think that is more bookish
9:57but in practice clinically if you can
9:59just feel
9:59and do a tap that will be more than
10:02enough
10:03in terms of palpation in terms of pain
10:06now also look for any obvious
10:08temperature you know that is always
10:10a basic thing to do check for any
10:12temperature um
10:14and look for any paraspinal spasm and
10:17also as part of the palpation
10:19as i said a lot of times you will see
10:22renal patient with renal stones coming
10:23up
10:24to your clinic so feel for the renal
10:26angle and feel for
10:28any tenderness across the renal angle
10:30and i have i i see at least
10:32one or two patients every month where
10:34patient has got a renal stone and they
10:35end up in your clinic in the
10:36in those cases they will not be tender
10:39in the midline
10:40but they will be tender in the um renal
10:42angle so do check
10:44the tenderness in the renal angle as
10:46part of your palpation
10:48so few things that i forgot to tell was
10:51one is
10:52when you feel the spine feel for any
10:54obvious step
10:55so if you feel for a step and
10:57occasionally in cases with
10:59higher grade lystases you will be able
11:01to feel the step
11:02if you feel the step and that can help
11:05you
11:05in diagnosing spondylolisthesis
11:09on your examination also don't forget to
11:12feel for tenderness across the psis for
11:16any sacroiliac joint pathology
11:20so the next part of examination will be
11:22movements
11:23so let me first demonstrate you uh what
11:27movements are in cervical spine
11:30and how to test them so the first thing
11:32that i would ask
11:33the patient is to you know bend
11:35affliction and extension and
11:37it's easier if you can demonstrate to
11:38your patient and ask them to copy you
11:40so i would usually ask them just mimic
11:42my movement so
11:44flexion is patient trying to bring chin
11:47to chest
11:48extension is looking to the roof
11:51then coming back to neutral and then if
11:53you can be straight here
11:55and then rotation towards the left
11:58and then rotation towards the right and
12:01same way back to normal
12:03and then you check for lateral flexion
12:05towards the left
12:07and lateral friction towards the right
12:09so once you assess this movement and if
12:11the patient has got restricted range of
12:12motion in the cervical spine that will
12:14tell you
12:15that patient may have cervical spine
12:17issues also occasionally
12:19you will see when the patient is doing
12:20lateral flexion or lateral rotation
12:23sometimes it will reproduce their
12:25symptoms um especially neurological
12:27symptoms in form of
12:28being getting worse you have you know
12:30parasthesia getting worse
12:32and that can also be of huge diagnostic
12:34value so this is
12:35how i test my movements of the cervical
12:37spine so now let's move on to the lumbar
12:39spine now
12:40move let's assess the movement of lumbar
12:42spines lumbar spine you check for
12:44flexion
12:44extension rotation and lateral flexion
12:47so let's demonstrate each
12:49one by one that how to assess the
12:51flexion
12:52so flexion is usually if you ask the
12:55patient
12:55to bend forwards and touch the ground so
12:58akash if you can just
13:00go down so this is the flexion
13:03and i will ask him to do the same facing
13:05away from the camera so if you can just
13:07just be on the other side like this
13:11and then try to bend so this
13:15is the flexion now the if patient is
13:17having a lot of pain
13:19and if patient is having
13:24limitation of movement of the spine then
13:26this flexion will be restricted
13:28now when you are checking for flexion at
13:30the same point
13:31i will do a show bus test so i'll tell
13:34you what is
13:35show bus test and how it is done
13:38so to do to do a show bus test you know
13:41you will read different books and
13:42different books will tell you
13:44how to do it differently but this is how
13:46i do it
13:47so you this is our the dimples so this
13:50is
13:51you just mark your dimples towards psis
13:53draw a horizontal line
13:55you draw a spot 10 centimeter
13:59above this line so this is 10 centimeter
14:01and then you ask the patient to bend so
14:02just bend it for me
14:03and see how much excursion it is so here
14:06if varun can bring the camera close you
14:08can see
14:08it is coming up to 16. so normally
14:12anything more than 15 is normal anything
14:15less than 15
14:16suggest that there is a restriction of
14:18the
14:19flexion in the lumbar region and that
14:21could be due to pain whether it's a disc
14:23prolapse whether it's a
14:24spondylolisthesis or it's ankylosing
14:25spondylitis
14:26there can be various pathologies but it
14:28tells you that there is some restriction
14:30so this is how you do
14:31the showbiz test so once you have
14:34assessed the flexion and you have done
14:36your show bus test then you do for
14:37extension so extension is just leaning
14:38back you can ask the patient to lean
14:40back
14:41and if there is any aggravation of the
14:43symptoms then that can also hind towards
14:45spinal system stenosis if the patient
14:48falls down or extends and he says
14:51your ass patient is getting better or
14:53worse in spinal stenosis occasionally
14:55equation will say the symptoms are
14:56getting worse
14:57now the third component is rotation so
15:00you can check rotation in either two
15:02ways the best
15:03way is to get the patient sit on a stool
15:06however i i'll
15:08tell you if you want to do it standing
15:10all you need to do is to hold the pelvis
15:12and then ask patient to rotate towards
15:14the left so just turn towards the left
15:16and then turns towards the right but
15:19even though i'm doing it
15:20i'm still not able to keep the pelvis
15:24you know stable so you can check the
15:27rotation when patient is
15:29sitting on a stool so the easiest way is
15:32get the patient sitting once the patient
15:34is sitting
15:35you eliminate any movement
15:38at the pelvic level and then you ask the
15:40patient to rotate so he will rotate
15:41towards the left
15:42and then towards the right so this is
15:45how you can assess the rotation
15:47now there is only one movement left that
15:48is the lateral
15:50flexion and i will show you how to do it
15:53so for lateral flexion you just ask
15:54patient to just
15:56turn tilt towards one side if you just
15:59on the
15:59left and you can assess depending upon
16:02how far he can
16:03lean down on that side and same on this
16:05side
16:07and then back up so occasionally when
16:10the patient is lateral flexing
16:11what it does is if somebody has got a
16:14disc relapse
16:15it will compress the nerve more and the
16:17symptoms will get
16:18worse so they will if i can be in the
16:21front of him
16:22so if i'm having a disc on this side if
16:24i do this it will press
16:26the nerve and it will make the symptoms
16:27worse so i will
16:29avoid going um or flexing on lateral
16:32friction on this side so i will be able
16:33to go
16:34this because that will relieve my
16:35symptoms but when i do this
16:37it makes the symptom worse so that can
16:39also give a very useful
16:41feedback for your this problem
16:45so once you have done the movements i
16:49move on to the gate i think
16:50it is also important so you want to
16:54assess
16:55what is what is a normal gate if you
16:57know what is the normal gate so you are
16:58looking if i look at my feet
17:00so if i am moving and this is my step
17:03width and this is my foot progression
17:05angle
17:06so this is how i normally walk but it
17:08can be changed in spinal problems
17:10say for example if somebody has got
17:13myelopathy
17:13they will walk with a much wider
17:16gate so what they will do is the the
17:20distance between the feet
17:21will increase their step or their
17:25step will be smaller and they will walk
17:27with a wider gate
17:28so somebody is walking with a wider gate
17:31then
17:32that can suggest towards a cervical
17:34myelopathy in later stages when the
17:36proprioceptive feedback is
17:38almost completely gone what they start
17:40doing is you know they start stamping
17:43in order to get some feedback in terms
17:46of where they are so this is
17:47a gate that you will typically see in
17:49patients with myelopathy
17:50in patients with this disease if the
17:52disc is compressed a lot especially l4
17:54alpha alpha s1 when there is weakness of
17:57dorsiflexion of the toe sorry of the
18:01ankle or or weakness of the extensors of
18:04the toe the ehl
18:05you can sometimes see you know a high
18:08stepping gate
18:09and you can have a foot slap so assess
18:12the gait
18:13at the same time you can also when you
18:15are assessing if somebody has got a
18:16cable whereas deformity to the spine
18:18they will work on the outer aspect of
18:20the affected side
18:22so assess the gate give some time to
18:24gate before
18:25you move on to your neurological
18:28examination
18:30so now i move on to my neurological
18:32examination and neurological examination
18:34will have four components so it will
18:37have
18:37assessment of tone it will have
18:40assessment of sensation assessment of
18:42power
18:42and reflexes so let's first start with
18:45neurological assessment of
18:47upper limb so for me to do an upper limb
18:51neurological assessment i have to have
18:53patient in anatomical position that is
18:54the
18:55palm facing forwards so
18:58first just let's assess the tone so just
19:01do this few times
19:03and do few times here if there is any
19:06hypertony or hypertonia hypotonia
19:08it will manifest at this stage so once
19:10you have assessment of that is the first
19:11thing i do
19:12then i move on to the sensation so
19:16c5 is the deltoid so this is all c5
19:21c6 is the outer aspect the forearm
19:25and the thumb
19:28c 7 is the middle finger
19:32c8 is the little finger and the inner
19:35aspect of the forearm
19:36and t1 is like a medial epicondyle that
19:40is what we say so this
19:41is the sensation and of course you will
19:43check on both the sides
19:44to look for any obvious asymmetry i'm
19:46not coming in the front because i will
19:47come in the view of the camera
19:48so this is my sensation done now let's
19:51move on
19:52to the assessment of power so for me c5
19:55again if you read different books and if
19:58you read
19:58different uh people will teach you
20:01differently but i will tell you how i
20:03assess my c5 so c5
20:04is for me shoulder abduction so i ask
20:07the patient to abduct
20:08and then to for completeness you want to
20:11assess
20:12what grade so deltoid for me
20:15is c5 for me c6
20:18is wrist extension so if patient extends
20:21a risk and you ask to keep it in the
20:23same position
20:24so c6 is wrist extension
20:27c7 is elbow extension so you ask patient
20:30to extend
20:31so for me c7 is elbow extension
20:35c8 you ask the patient to grip your hand
20:37so that will
20:38see it that is finger flexion and t1 is
20:41spread the fingers and ask them to keep
20:43spread so that is
20:45the examination of or the myotomes
20:49complete
20:50then of course as part of the completion
20:52you will do a biceps reflex you will do
20:53a brachioradialis or supinator reflex
20:56and triceps which will
20:59complete your examination i am not
21:01telling you how to do it because that is
21:02medical
21:03student stuff so once you have assessed
21:06the upper limb
21:07the next thing that you want to assess
21:09is if it's a lumbar spine problem
21:11how to do a neurological assessment of
21:13the lower limb so now let's move on to
21:15the lower limb examination
21:16so like with upper limb um your lower
21:19limb neurological examination starts
21:21with assessment of the tone
21:22so move the knee few times both sides to
21:25assess
21:26the tone whether there is any increased
21:27tone or decrease tone
21:29once you have done the assessment of the
21:31tone then you check for sensation
21:33and the way i do it is l1 is
21:36upper thigh or when you say hand in the
21:38pocket is l1 l2 is mid thigh
21:41l3 is front of the knee l4
21:44is inside of the leg l5 is outside of
21:47the leg covering
21:48the majority of the dorsum of the feet
21:51and s1 is
21:52outside of the sole once you have done
21:55this move on to the myotome so the hip
21:57flexion
21:58is the first thing you do that is l2
22:00that is hip flexor
22:02so you can ask the patient to do first
22:05on its own
22:06and then to quantify the power you can
22:09do it
22:10against the resistance the same thing
22:11you will do for
22:13knee extension that is l3 so push
22:16against
22:17l3 l4 is ankle dorsiflexion so ankle
22:20dorsiflexion
22:22against to see the power ehl
22:25is l5 so ask the patient to bring the
22:28big toe towards yourself and of course
22:29you will do this
22:30on both the side not one side and s1 is
22:33pressing down like you are pressing a
22:35gas pedal in your car so this is
22:37s1 once you have done this you will
22:41do the completion by checking for knee
22:44reflexes and ankle reflexes
22:46that will complete your neurological
22:48assessment
22:49of your lower limb
22:53now the neurological examination of the
22:55lower limb can also be done
22:57while patient is standing up this was
22:59the demonstration that i did was while
23:01the patient was lying down
23:02if i do the same thing standing up so
23:05if i have to show it so if i do this l2
23:09is the hip flexion so you can check both
23:12sides
23:12l3 is you ask the patient to go down and
23:15go up so knee extension
23:17is l3
23:20then you ask the patient to stand on the
23:25heels so if the patient can walk like
23:27this
23:28then that means the l4 is
23:31working well and this is how you assess
23:33for l4
23:35when you do the tender work test when
23:38you assess for
23:39power of the hip abductor so if i am
23:41standing on
23:42right side i am checking l5 of right
23:45side
23:46when i am checking for
23:49if i am doing the tender work test or
23:52asking the patient to stand on the left
23:53side then you are checking for
23:55l5 so hip abductor is l5
23:58and s1 if you ask the patient to tiptoe
24:01then
24:01this is s1 so you can do this assessment
24:04while
24:05standing up as well now there are few
24:07reflexes which
24:09i have not talked about for completion
24:11sake of course you will check for
24:13abdominal reflexes you can check for
24:16bulbour nurses
24:17flexes and for your completion of
24:20neurological examination
24:21you you need to do a parental
24:23examination
24:25in almost all spine cases so do a
24:27parental examination
24:29and of course you check for the
24:31peripheral pulses
24:32to differentiate a spinal cordication
24:34from a patient with a vascular
24:36qualification this will
24:37complete the neurological examination
24:39now let's cover some individual
24:42clinical conditions so let's first cover
24:43spinal cervical spondylosis
24:46so you will see these patients typically
24:48there will be males you can see it in
24:50females as well
24:51they'll be in their 40s or 50s
24:53complaining will give history of pain in
24:55the neck
24:56and heaviness on this this trapezoidal
24:59area or the shoulder area
25:01and in later stages can have
25:04neurological symptoms in form of pinch
25:05needles and numbness
25:07so this will be the typical history and
25:10in terms of diagnosing them
25:12once you have taken history you will
25:14find that they are
25:15tender in their midline in the lower
25:18cervical
25:19region because usually c5 c6 is the
25:21communist level followed by c6 c7
25:24and there might be restriction in range
25:26of the movement now in terms of special
25:28test
25:29apart from neurological abnormalities
25:31that you will pick up in your clinical
25:32examination
25:33i think one test that i would like to
25:35demonstrate is which is called spurling
25:37test
25:37so let me show you what is spelling test
25:39so to do spelling test
25:41let's presume that akash is having
25:43symptoms on his
25:44left side so he's having you know say
25:47for example parasites on his
25:48left side and some tingling in his thumb
25:51because of
25:52potential c5 c6 disc so what you want to
25:56do the patient is first to you know
25:57extend the neck
25:59and then lateral flex
26:02a lot of times patient will report
26:04worsening of the symptoms
26:06so this will be a positive test however
26:10if they don't reproduce the symptoms you
26:12can add the third component
26:14that is the axial compression so just a
26:16gentle
26:17constant compression on this side and if
26:19it reproduces
26:20pains and symptoms especially the
26:22radicular pain
26:24then this is a positive test
26:27the second test i would like you to
26:30know which not a lot of people will do
26:33is
26:33just opposite of spurling test is called
26:35distraction test
26:36so it's very easy put one hand under the
26:39occiput
26:39and the other hand underneath the jaw
26:41just for demonstration so that my hand
26:43doesn't come
26:44and just a gentle constant distraction
26:47so what it does is it relieves the
26:50pressure onto the nerves
26:52and if it makes the patient's symptoms
26:53better then that is also
26:55a positive test so the next clinical
26:59condition that i would like
27:00to cover is what we call is a cervical
27:03myelopathy
27:04now the same patients when they become
27:06more older
27:07and the disease progresses further it
27:10starts to press the spinal cord and then
27:13you have a clinical condition which is
27:14called cervical myelopathy
27:16now the patients will typically be in
27:18their you know 60s or 70s or 80s
27:21and will come to your clinic complaining
27:24of of course pain in the neck
27:26they can have also neurological symptoms
27:28in form of tingling
27:30they can give history of you know
27:32occipital headache
27:34but most importantly they will come and
27:36they will tell you
27:38that they are becoming more unsteady on
27:40their feet so they are not able to walk
27:42properly
27:43they are finding difficulty in doing
27:44day-to-day activities especially
27:46for males if i have to button my shirt
27:49and unbutton my shirt
27:50it requires a lot of well-coordinated
27:52movements of intrinsics of the hand
27:54so they will lose their dexterity and
27:57they will
27:58struggle with these day-to-day
28:00activities for females you know just
28:02putting their undergarments on or doing
28:03to direct day-to-day activities
28:05also becomes difficult so when you
28:08this will be the typical history that
28:10they will give on examination again
28:12they will have they can have uh
28:15you know a pain restricted range of
28:17movement
28:18and there are certain few things a few
28:21tests that you will see and i will try
28:23to cover them one by one
28:25which will help you in a way that that
28:27might guide that it is
28:29a cervical myelopathy
28:32so two or three things that i will
28:34definitely
28:36few things that i will test in patients
28:38with myelopathy
28:39while standing up is the first thing is
28:42what we call the rhombox test and
28:43romberg test
28:45is a test for coordination and
28:47coordination is governed by
28:49a cerebellum so it's extremely important
28:52that you do do the rum box test
28:54so to do the rhombus test you need to
28:57ask your patients to bring
28:58both feet together you can also ask the
29:01patient to bring their arms up
29:03and then close their eyes and reassure
29:05them that
29:06you will not let them fall and ask them
29:08to stand so if they have got a good
29:10proprioceptive feedback you know the
29:12posterior column is good the cerebellum
29:14is good
29:15they will be fine otherwise they will
29:17swing and they will tend to fall
29:19and this is the main reason that
29:21incidence of fall
29:22is quite high in patients with
29:25myelopathy
29:26the second sign that you can do is what
29:28we call lermite sign is
29:30just ask patient to bring the chest to
29:32the chin and in this position
29:34they will report electric a shock like
29:36sensation going down so that will
29:38reproduce the symptom
29:40and that is a positive hermite sign
29:42however it can be
29:43present in other clinical condition as
29:45well such as multiple sclerosis
29:48so be value of it the third thing that
29:51we call is which call is
29:53a grip or release test so you ask these
29:56patients normally
29:57if i have to grip like this i can do it
29:59really really fast so grip
30:00and release grip and release grip and
30:02release so normal patient should be able
30:04to do more than 20 times in a minute
30:06but a patient with cervical myelopathy
30:09will struggle
30:10and will not be able to complete this
30:11task and they will
30:13find it difficulty so if they are able
30:17not to if they cannot do open end close
30:1920 times
30:20that is also a positive test which can
30:22end towards
30:23the cervical myelopathy now the other
30:27there are a few reflexes we will talk
30:29about and i'll show you how it is
30:30let's first talk about hofmann reflex i
30:33have already uploaded a separate video
30:35just on often reflects in a patient who
30:37was myelopathic
30:38so if you want to see how a real patient
30:41will have when please do watch that
30:43video for hoffman reflex
30:45you just need to take your hand and keep
30:48it relaxed on your hand
30:50and then you flick the middle finger so
30:52you flick
30:53the middle finger and as you flick in
30:56patient who have got
30:57a positive reflex they will be finger
31:00flexion so they will be twitching and
31:01every time
31:02you flick the finger this the thumb and
31:05index finger will go like this so that
31:07will be a positive test
31:09again suggestive that it could be a
31:11cervical myopathy
31:13so the second reflex what we call is an
31:16inverted radio reflex so
31:18normally as part of a neurological
31:19examination you will do a
31:21you know brick radialis or supinator
31:24reflexes
31:25normally when you tap here you will see
31:27flexion
31:28or contraction of the brachioradialis
31:30but in an inverted reflex
31:32if you look at the finger you can see
31:34there will be flexion so this
31:35is a positive test which can suggest
31:38a patient may have myelopathy
31:42so the third reflex that you should
31:43always do in patient with
31:46suspected myelopathy is a babiniski
31:49reflex so normally
31:50you will see when you just gentle stroke
31:53this
31:53finger will flex and will be together
31:56but
31:57if they extend and fan
32:00that is a positive babiniski's reflex
32:03suggestive of
32:05a possible myelopathy
32:08so once you have done these tests
32:11in patient with myelopathy if you have
32:13got positive
32:15reflexes or test and that can indicate
32:17myelopathy
32:18um the the next clinical condition that
32:20i would like to cover
32:21is what we call is thoracic outlet
32:23syndrome
32:24now it exists quite commonly but
32:26uncommonly appreciated
32:28and diagnosed thoracic outlet syndrome
32:31is a clinical condition in which there
32:32is compression of
32:34brachial plexus and the subclavian
32:36vessels
32:37in the thoracic outlet you can divide
32:39them into three different areas but
32:41essentially
32:43it is involved in around one to two
32:45percent of the normal population
32:47it is more in females than in males and
32:50if the symptoms that you can have
32:52you can have unilateral symptoms or
32:54bilateral symptoms the symptoms
32:56are usually a pain in the trapezil area
32:59that is the difficulty because the
33:00trapezial pain is also seen in
33:02a patient with cervical disc problems so
33:05that can mask it
33:06you can also have a weakness or
33:09neurological
33:10findings as you would see in patient
33:12with cervical disease again adding to
33:14the difficulty of
33:15diagnose diagnosis
33:18what you have in terms of neurology that
33:21is different from cervical this prolapse
33:22prolapses it is
33:24a non radicular pain and the
33:26distribution
33:28is is quite wide so ah wide
33:32dermatomal distribution is
33:33characteristic of
33:35thoracic outlet apart from neurological
33:38symptoms
33:39in thoracic outlet you can also have
33:41some vascular symptoms as well because
33:43subclavian vessels can be compressed
33:45so you can have reynolds phenomena like
33:48symptoms such as pallor
33:51and other vascular issues or distended
33:54veins in the neck
33:55that can help you towards the diagnosis
33:57so this is the typical history that i
33:59will present
34:00on examination uh yes of course you will
34:03find
34:04neurological abnormality and and there
34:07are some special tests
34:08that you should know about the first
34:10test that i would like you to learn
34:12is what we call is the adsense test so
34:15let me demonstrate you what is adson
34:16test
34:18so to do the acts and test you get the
34:20patient seated
34:22now the position i'm going to examine
34:24akash right
34:25hand so shoulder in slight abduction
34:28elbow extension forearm in supination so
34:31this is the position in which
34:33your arm will be and your hand will be
34:36on the radial pulse
34:37then what you ask a patient to do is you
34:40ask the patient to extend the neck
34:42and then lateral flex and then take a
34:45deep breath so
34:46ask to take a deep breath and then hold
34:51so if the patient holds the breath if it
34:53reproduces the patient's symptoms
34:55or obliteration of a radial pulse
34:59is a positive accent test
35:02so the second test which is called a
35:05rights test
35:07again what you do is you take the
35:09shoulder abduct up to the 90 degrees
35:11and then externally rotate and then
35:15forearm should also face
35:18of the front so pronated and in this
35:21position
35:22keep it for some time and any
35:25obliteration
35:26of radial pulse or reproduction of
35:28patient symptoms
35:30is a positive test now the secondly the
35:33same thing
35:34what you do is you take the arm up and
35:36hyper abduct
35:37and again the same thing feel for the
35:39pulse so any obliteration
35:41or any reproduction of patient symptoms
35:44is a positive test
35:47so the third test that i use sometimes
35:51not frequently because it requires a lot
35:53of time is what we call a roots test so
35:55roots test
35:56you keep the arm up so shoulder abducted
35:58up to
35:5990 degrees elbow flexed and then you ask
36:02the patient to open and close the hand
36:04for roughly three to five minutes and if
36:06it reduces patients pain and symptoms
36:09then that is the positive test
36:12let's move on to our next clinical
36:14condition which is called
36:16a lumbar disc prolapse now i think most
36:18orthopedic surgeons will see
36:21at least few patients of pain in the
36:23back in the clinic and this is usually
36:25one of the communist
36:26patients and they will give history of
36:29either lifting heavy weight
36:31or pain in the back which is radiating
36:33either one side
36:34or bilaterally so there will be history
36:38of
36:38pain in the back as well as sometimes
36:41there will be history of radiation
36:42pain will get worse in activities which
36:45is like
36:46lifting heavy weights bending forward
36:48coughing sneezing
36:50will make the pain worse they will on
36:53when you examine them
36:54you will see they look in pain sometimes
36:57there can be
36:58a poor coronal balance as i showed you
37:00before just as to decompress the disc
37:03they can have a lot of paraspinal
37:06muscle spasm and they will have limited
37:09flexion when you try to
37:10flex them of course they may have
37:13neurological
37:14abnormalities when you do a neurological
37:16examination
37:17now there are a lot of tests that are
37:20important
37:20relevant and very pertinent when you are
37:23seeing the patients with lumbar disc
37:25disease
37:26so i will cover them one by one and i
37:28think this is the sequence that you
37:30should follow
37:30in your clinic as well so the first
37:32thing that we will do is
37:34what we call is a straight leg raise
37:36test
37:37so the straight leg raised test is the
37:39first test that you should be doing
37:41when you are seeing a patient with
37:43lumbar disc disease now um
37:45it is a test which is to check
37:48for lumbosacral root nerve root
37:50irritation
37:51now the first thing is that it is a
37:53passive test so you don't ask patient to
37:55lift the leg you lift the leg yourself
37:58so for this you keep the knee extended
38:00so knee has to be extended
38:02you keep one leg one hand underneath the
38:05patient's
38:07ankle and then slowly lift it up and
38:09then you keep looking at the patient
38:11so typically patients will reproduce
38:14their pain not in the back but going
38:17down the leg
38:18between roughly around 30
38:22to 60 degree of flexion so between this
38:24range
38:25usually they will complain of the
38:27reproduction of the symptom that is the
38:29leg pain not the back pain
38:31anything past 60 degree becomes
38:33irrelevant and it's usually related to
38:35other causes whether it's a hip cause or
38:37something else but straight leg raise is
38:40typically positive between 30
38:42to 60 degree
38:45of the range so that is if the patient
38:47has got
38:48pain reproduction of the pain that is a
38:51positive straight leg raise taste
38:54now when you read the books you will um
38:57some some men some books will mention
38:59that straight like rest is to be lesser
39:01use test but less serious test
39:03my interpretation of leicester's test is
39:05as follows
39:06so say for example if i was lifting
39:09akash leg up to here
39:10and then the patient symptoms of leg
39:13pain
39:14where coming and his the test is now
39:17positive
39:18so all i will do is i will just lower
39:20down the
39:21leg slightly till the patient reports
39:23the patient symptoms are better
39:25and then again you stretch the nerves
39:28and you dorsiflex the
39:30foot as soon as you dorsiflex the foot
39:33that will
39:33stretch the nerve more and that will
39:36again reproduce the pain going down the
39:37legs
39:38and that is a positive lasso gives
39:41test so the third test that i like to do
39:43most in my clinic with a patient with
39:46lumbar disc prolapse is what i call a
39:48boosting test
39:50now for me in my experience if this is
39:51positive most of the times
39:53if you get the patient's mri they will
39:56definitely have
39:57there is a very high chance they will
39:59have a disc prolapse
40:00so what you do is again you do the slr
40:03so say for example
40:05this is the position in which
40:09the patient is reproducing the patient's
40:12symptoms so all i will do is at this
40:15point of time
40:16i'll fix this angle so i either
40:19in in the shoulder say for example now
40:21the angle is fixed
40:22so what i do is then you bend the knee
40:24slightly and as soon as you bend the
40:26knee what will happen is
40:28the tension on the nerve becomes less
40:31and
40:31then patient will say or will if you
40:34look at the patient's face they will
40:35report the symptoms are getting better
40:37however in the same flexed position you
40:40don't need to flex too much
40:41flexion just enough for patients
40:43symptoms to get better
40:45and then use any hand or thumb and press
40:48it in the popliteal fossa and what it
40:50will do is it will
40:51stretch or it will tension
40:54the sciatic nerve like string of a bow
40:59and as soon as you press it every time
41:00you press it patient will wince and this
41:02is a positive test and a very sensitive
41:05test for
41:06cervical disc prolapse so i meant a
41:09lumbar disc prolapse not um the cervical
41:11disc prolapse
41:12now the other um test that you need to
41:15do next is what we call is a cross-leg
41:17slr so if akash is having symptoms on
41:21the right side
41:22if i do the slr on the left side
41:25and if i raise it up and if it is
41:26reproducing the pain
41:28and symptoms on the opposite side that
41:31is again
41:31a very sensitive test for a lumbar disc
41:34prolapse and usually it is the central
41:36this prolapse
41:38so one test that you can do in your
41:40clinic sometimes if you think patient
41:42is symptoms are whether it's organic or
41:46whether it's hysterical or whether the
41:47patient is malingering
41:48what i call is a flip test it's like a
41:50sitting slr
41:52so what i would do is i will get the
41:54patient to sit
41:55and say for example if he's having pain
41:57in his left
41:58side i will just do this and this is
42:00again this should reproduce the
42:02patient's
42:02symptoms so if it's not reproducing the
42:04patient's symptoms
42:06while sitting up that can be a hint that
42:08patient is malingering
42:09however if it is then again it is a
42:12positive test for lumbar disc prolapse
42:15so the last test that i will do in
42:16somebody who has got lumber dysprolapse
42:18at a higher level
42:20which is opposite of slr in which we
42:22stretch the sciatic nerve
42:24and this test is called a femoral stress
42:27test and this is usually seen in this
42:29relapse
42:31up at the higher level where there is
42:34involvement of l234 that is femoral
42:37nerve
42:37so for this the first thing is that you
42:40put your one hand
42:40under the pelvis to stabilize the pelvis
42:43the second
42:44thing is bend the knee so hand on the
42:47pelvis
42:48um bend the knee then i will put one
42:50hand
42:51underneath the patient's
42:54knee so that i can extend the hip so
42:56once i have stabilized it
42:58bend the knee and then i'm going to
43:02extend the hip so in this position i'm
43:04stretching the femoral nerve to its
43:06maximum
43:06so if it is reproducing the patient
43:08symptoms that is a positive
43:11femoral stretch test suggestive of a
43:13lumbar disc prolapse
43:15the next clinical condition and that i
43:17would like to talk about
43:18is spinal stenosis again it is
43:22very common in patients are common
43:25permanent patients who are elderly
43:27even in young patients these days and
43:29it's very common presentation
43:31in our clinic so patients usually will
43:34have
43:35your age will be usually more than 60
43:38and it's more common in males they will
43:41give history of
43:42pain in their back and sometimes they
43:45will also give history of buttock pain
43:47now the typical history that they will
43:48give is what we call the history of
43:50claudication is
43:51that after walking certain distance or
43:53certain time
43:54they will feel heaviness in the buttocks
43:58or in the legs and then they will have
43:59to stop
44:01so history is quite typical in these
44:04cases some patients will report that
44:08when they walk uphill they feel less
44:10pain because when they bend forward
44:12it actually opens up the canal and it
44:14makes their symptoms better in a similar
44:16fashion
44:17in developed country when you see all
44:19these old
44:20males or females are leaning on the
44:23shopping trolley
44:24and then they say that when they go for
44:26shopping and when they
44:28carry the trolley they are able to walk
44:29further so this is also
44:32a positive history now once
44:35you go for examination now most of the
44:38times the neurological examination
44:40in spinal stenosis patients are usually
44:43normal so you will see that there is no
44:45weakness
44:46there is no parasthesia that is quite
44:47typical it's usually the history
44:50i think in terms of special tests i can
44:52think of only one test
44:53which is called a chems test and i will
44:55show you how to
44:57do a chems test so in kent's test what
45:00you do is first you ask
45:02the patient to extend so you extend so
45:04this way this is extending the hip as
45:06well
45:07and then if the symptoms are on this
45:09side you ask patient to lateral bend so
45:11this way
45:11you are maximally compressing the spinal
45:15canal and if
45:16the patient reports the reproduction of
45:18their symptoms
45:19then that is a positive test for spinal
45:22stenosis the next clinical condition
45:24that i would like to cover
45:25is a sacroiliac joint and pain
45:29which is responsible
45:32when you have involvement of sacroiliac
45:34joint now sacroiliac joint can be
45:35involved
45:36in pregnancy in trauma in infection
45:39or in ankylosing spondylitis or other
45:42inflammatory condition
45:43now the typical history can mimic the
45:46pain
45:46of lumbar disc disease like pain in the
45:49back but it will be more on the sides
45:52which will be aggravated by physical
45:54activity such as
45:56you know clear standing prolonged
45:58sitting
46:00and stairs can make it worse so you it
46:03can mimic symptoms of back pain so
46:04always look for
46:06a sacroiliac joint pathology when you
46:08are examining patient with back pain
46:10now i am going to show you some special
46:12tests
46:13which you should do when you are
46:14suspecting a sacroiliac joint pain so
46:16i'll cover five or six tests
46:18to cover for sacroiliac joint
46:21so the first test that i would like to
46:23demonstrate is what we call is a gas
46:25lens test
46:26now gasoline test is
46:29quite a sensitive test for sacroiliac
46:31joint pathology
46:32so for this your prerequisite is that
46:35patient should be on the edge of
46:37you know out of there so half of the
46:39body is on the table
46:40and half of it is outside so if i am
46:43testing
46:44the right side the right side sacroiliac
46:46joint should be
46:47off the table now the second
46:49prerequisite is
46:50then you should let hang this this knee
46:54off the table
46:55once you hang this knee then you flex it
46:57so what you do is you flex the hip
46:59and then extend this knee and this way
47:02you are applying
47:03a rotatory force onto the sacroiliac
47:06joint and if it reproduces space in
47:08symptoms then that is a positive test
47:11so now the second test which is much
47:13easier is what we call a figure of four
47:15or
47:15fiber that is flexion abduction external
47:17rotation test so if i am testing
47:19the right side i will put this leg in
47:22figure of four and then
47:24one hand on to the patient knees other
47:27hand
47:28onto the opposite side of the eyelet
47:30crest and i will do this so if i'm doing
47:32this
47:32i'm testing the right side not the left
47:35side so
47:36you put the fig leg in figure of four of
47:40the same side which you are testing
47:42so the third test that i will do is what
47:44i call is it a
47:45thigh thrust test so thigh thrust test
47:48is
47:48nothing but get the hip to 90 degree
47:52reflection
47:53knee to 90 degree reflection and then
47:56just some
47:56constant gentle sustained pressure
48:00and if it reproduces patient symptoms
48:03then
48:04that and it reproduces pain across the
48:06side joint
48:07that is a positive test so the last two
48:10tests
48:11are compression test and a distraction
48:13test and it's
48:14very easy to perform it's the same way
48:17as
48:18when we do check the stability of pelvis
48:22in
48:22a trauma patient so compression test is
48:24nothing but compression
48:25of pelvis from both the sides and if it
48:28is reproducing patient pains that is a
48:30positive test
48:31and in distraction opposite instead of
48:33compression you put your hand on asis
48:35and put a distraction
48:36so if you do these five tests and if
48:39more than
48:39three or more tests are positive then
48:41that is a very good chance that patient
48:43has
48:44sacroiliac pathology so the next
48:46clinical condition that i would like to
48:48cover
48:48is called scoliosis now scoliosis is not
48:52a very difficult condition to diagnose
48:54you see them in kids you see them in
48:56adolescence you see them in adults
48:59but they will give a typical history of
49:02uh
49:02you know deformity of the spine um you
49:05know shoulders are falling apart
49:07and they can see sometimes rib hump so
49:10period the patients will present in
49:11variety of
49:12ways but it's very easy to diagnose
49:15clinically
49:16you can see you know asymmetry in psis
49:20you can see ribham you can see you know
49:23when you look from the back you will see
49:25the curves of the
49:27scoliosis so it's not a very difficult
49:29condition to diagnose
49:31but one or two things that i would like
49:32to for you to know is
49:34one is how to what is a plum line
49:38and what is an adam forward flexion test
49:42so atom forward flexion test is
49:46you can use it as a screening test to
49:47differentiate between
49:49whether the curve is functional or
49:51structural so functional means whether
49:53if it is correctable functional means it
49:56has become rigid
49:57so if say for example um akash had
50:00a rib hump on on the left side and there
50:04was a visible scoliosis
50:06and there was a curve then all you need
50:08to do is ask the patient to bend forward
50:10and try to touch the feet as if you are
50:12doing it
50:14in checking the flexion so if it is a
50:17functional curve
50:18when you feel for this the spinous
50:20process they will become
50:21aligned so the curve will become
50:23correctable however if its a structural
50:24curve
50:25you will see the curve not corrected and
50:28you will start seeing the ribbon
50:29on the side wherever it needs to be seen
50:33so this is
50:34what we call is atom forward
50:37flexion test now the second thing i want
50:41you to understand is what we call a
50:42plumb line so plumb line is something if
50:44we say for example if you draw a
50:45vertical line
50:46say for example if i draw a line and if
50:49i draw this tape
50:51straight from the center down to the
50:53center of the both feet usually in a
50:55normal patient this will pass through
50:56the gluteal cleft
50:58if the patient has got scoliosis then
51:01and if it's not
51:02compensated then this will not pass to
51:05the one side
51:06so this will tell us that there is an
51:09issue and the patient may have
51:10scoliosis the last clinical condition
51:14that i would like to cover
51:15is what we call as an ankylosing
51:17spondylitis
51:18you know it's an autoimmune condition it
51:20is far more common in males
51:23than females usually it's a young male
51:26in his
51:26early 30s or 40s they will complain of
51:30back pain and they can have associated
51:33eye problems like uti urethritis or
51:37sometimes eye problem in form of uveitis
51:40pain is typically worse thing in the
51:42morning they have history of morning
51:43stiffness
51:44and occasionally later on subsequently
51:47they will have
51:49progressive deformity like loss of
51:51horizontal gauge
51:52and other deformities respiratory
51:54difficulty in breathing and other
51:55symptoms
51:55starts to creep in so it's it's a very
52:00easy condition to diagnose if you do the
52:03blood test then most of them will have
52:04come up with the
52:06positive hle b27 now there are three or
52:09four tests that i would like to
52:10you to know um in enclosing spondylitis
52:13one of
52:14which we have already covered on which
52:16we call is a show bus test so in showbiz
52:18test if somebody with an angst bond
52:20you will see mark restriction inflection
52:23when you're doing this test so show us
52:24test
52:25will be positive in uh encoding
52:28spondylitis the second test
52:29has also been covered in the sacroiliac
52:32joint pathology if you do
52:33figure a four test or the test which all
52:36the tests that are positive
52:38in sacroiliac joint like the compression
52:41test the distraction test
52:43and the other two tests that i've talked
52:44about will also be positive
52:47in this the third thing that i would
52:49like to
52:51check in these patients what we call is
52:53a chest expansion
52:54so you will do a chest expansion and you
52:57will see
52:58a lot of these patients will have a
53:00decreased chest expansion
53:02and i will show you how i do it so to
53:05check the expansion of the chest wall
53:07you take and measure tape
53:09and at the level of the nipple and then
53:11you ask the patient to take a deep
53:13breath
53:14so take a deep breath so in his case i
53:17can see it was initially
53:19106 it's gone to one or ten so anything
53:22more than
53:23three centimeters is considered as
53:27negative so one the other test that you
53:30can do
53:30in patients is what we call as a wall
53:33stress or occiput wall test
53:35all you want is your patient to touch
53:37their heel
53:38to the back of the wall
53:41their back and the head what you will
53:44notice this patient with ank spawn will
53:46have a positive sagittal balance
53:48and even if they want to they are unable
53:50to touch their occiput and as the
53:52deformity increases
53:54the distance between the occiput and
53:56wall will
53:57become more so if the patient is not
53:59able to touch all these three together
54:01that is a positive test
54:03so the last thing that i would like you
54:05to
54:07know is what we call is a chin bro angle
54:09so if this
54:10is the vertical axis
54:13you know when we measure our sagittal
54:15balance and if you see the face of akash
54:18it's like this so these two are parallel
54:22so this is almost zero degree but what
54:25will happen
54:26as if somebody has got flexion
54:29deformity or the positive satchel
54:31balance the neck will become
54:33will progressively start to become you
54:35know it will bend more and more
54:36so if say for example if he is like this
54:39so if this
54:40is my vertical axis and this is the axis
54:44of the
54:45face so this this is the chin bro angle
54:48so as
54:49the deformation will progress the chin
54:51bro angle will start to increase more
54:53and more in ankylosing spondylitis
54:57so because this was a demonstration on
54:59how to do a
55:00comprehensive spine examination i have
55:03tried to make this video as
55:04comprehensive as possible
55:06so that you feel confident in dealing
55:08with patients with spinal pathology
55:10i have also uploaded other parts of the
55:13body
55:13and detailed videos of other parts of
55:16the body such as shoulder
55:19knee ankle wrist and hand so
55:22you can watch them if you like this
55:23video give us a thumbs up
55:25do subscribe and do share our channel

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