Published on January 21, 2014
Cervical spine Consist of 7 vertebra 8 nerves Give two plexuses Cervical plexus ( C1-C5) brachial plexus ( C5-T1) Phernic ( C3,C4,C5) mucocutanous n (C5-C7) Lesser occipital (C2) axillary n (C5-C6) Supraclaviclular ( C3,C4) median n (C5-T1) radial N (C5-T1) ulnar n (C8-T1)
Cervical spine History * acute trauma History of Falling down , vehicle accident . Any patient unconious form after heard injury you should assumed it as cervical spine injury. ABC, WAIT FOR help , x –ray frontal & lateral
Cervical spine History * PAIN :- analysis of pain Acute ,sub acute ,chronic Onset ,duration , character , severity ,radiation ,reliving ,aggravating factor At end of day /at night , other joint affected *Weakness in upper limb *Paraesthesia
Cervical spine History Pain and difficulty turning the head and neck, examples are: → Disease of atlanto-occipital joints produces pain radiating to the occiput. → Spondylosis of the middle and lower cervical spines causes pain radiating to the upper border of trapezius, interscapular region, and the arms. → Irritation of the C6 & C7 nerve roots can give rise to referred pain in the interscapular region, radial fingers, and thumb. → Irritation of C8 can cause pain on the ulnar side of forearm, ring, and little fingers.
Cervical spine Physical examination: Look Observe the posture of the head and neck and note any abnormality and deformity, e.g. loss of lordosis. Feel → The midline spinous processes → The paraspinal soft tissues → The supraclavicular fossae – for cervical ribs or enlarged lymph nodes → The anterior neck structures including the thyroid
Move: → Assess active movements: o forward flexionPut your chin on your chest o Extensionlook upwards at the ceiling as far back as you can o Lateral flexionPut your ear onto your shoulder o Lateral rotationLook over your right/left shoulder
→occiput to wall test → Gently perform passive movements if there are reduced active movements and see if the end of the range has a sudden or gradual resistance and whether it is pain or stiffness that restricts movements
Cervical spine Physical examination – Cont. ( Neuro exam): Movement C5- shoulder abduction C6 – elbow flexion wrist extension C7- wrist flexion REFLEXES:Deltoid (C5) BICEPS (C6) TRICEPS (C7) Sensory C2,C3 neck shoulder C3,C4 shoulder posterior ARM Medially T1 Laterally C5 ,C6 FOR ARM T1 MEDIALLY C6 laterally HAND Lateral C6 Middle finger C7 MEDIALLY C8
Thoracic spine( T1-T12) History → Commonly, localized spinal pain, examples are: Ankylosing spondylitis produces pain in the thoracolumbar region Acute thoracic spinal pain may be due to vertebral prolapse due to malignancy, or infection; especially if there was systemic upset or fever is present → Less commonly, symptoms of paraparesis including sensory loss, leg weakness, and loss of bladder or bowel control
Thoracic spine Physical examination: Look With the patient standing, inspect posture from behind, the side and the front, noting any deformity, e.g. rib hump or abnormal curvature. Feel → The midline spinous processes → The paraspinal soft tissues → If there is increased prominence of one or more spinous processes implying anterior wedge-shaped collapse of the vertebral body – often related to osteoporosis. Move Ask the patient to sit with arms crossed, and to twist round and look at you.
Lumbar spine LUMBAR NERVES( L1-L5) SACRAL NERVES ( S1-S4) LUMBAR PELUXES ( L1-L4) illioingunal (L1) , iliohypogastric (L1) , genitofemoral (L1-L2), Femoral (L2-L4) Obuturator (L2-L4) SACRA L PELUXES SCIATIC NERVE (L4 –S3) 1- Common peroneal 2- Tibia
Lumbar spine SCITICA :- PAIN extend from buttock , poster-lateral of leg , lateral aspect of foot Common risk factor :- 1-Herniated disc 2- pregnancy 3-osteoarthritis 4- wrong IM INJECTION
Lumbar spine History → Low back pain is an extremely common complaint → Sacroilitis produces pain that is referred down both legs to knees → Consider abdominal and retroperitoneal pathology, e.g. abdominal aortic aneurysm, pancreatitis, peptic ulcer, renal pathologies.
Lumbar spine Red flag features for acute low back pain: → In History: Age < 20 yrs or > 55 years Recent significant trauma (fracture) Pain: Thoracic (dissecting aneurysm) Non-mechanical (infection/ tumor/pathological fracture) Fever ( infection) Difficult micturition Fecal incontinence Motor weakness Saddle anesthesia Sexual dysfunction Gait change ( cauda equina syndrome) Bilateral sciatica
Lumbar spine Red flag features for acute low back pain: → In Past medical History: Cancer ( metastasis.) Previous steroid use (osteoporotic collapse) → In Systemic review: Weight loss/malaise without obvious cause (e.g. cancer)
Lumbar spine Physical examination: Look Examine the patient standing. Look for obvious abnormality such as decreased/increased lordosis, obvious scoliosis soft tissue abnormalities such as a hairy patch or lipoma that overlie spina bifida. Feel Palpate the spinous processes and the paraspinal tissues. The L4/L5 interspinous space is palpable at the level of iliac crests.
Move → Flexion: ask the patient to try to touch his toes with his legs straight → Extension: ask the patient to straighten up and lean back as far as possible → Lateral flexion: ask the patient to reach down to each side touching the outside of the leg as far down as possible while keeping the legs straight
LUMBER SPINE Physical examination – Cont. ( Neuro exam): Movement L2- hip flexion L3 – Knee extention L4-dorsiflexion S1-planterflexion REFLEXES:Quadriceps (L3-L4) Achilles (l5-s1) Sensory
Lumbar spine Physical examination-Cont.: Special tests: Schober’s test for forward flexion Root compression tests: Straight leg raise Tibial nerve stretch test Femoral nerve stretch test Flip test Sacroiliac joints test
Lumbar spine Schober’s test for forward flexion 1- Erect position. 2- Select 2 bony points,10cm apart and mark it. 3-Maximum flexion on lumbar with fix knee. 4-the two points should separate by at least a further 5cm.
Straight –Leg raising test -knee straight,slowly lifted the leg. -note for any tightness and pain in the buttock (around 80-90 ) -passive dorsiflexion,increase the pain. -bow-string sign : bending the knee slightly,release the pain.then apply firm pressure behind lateral hamstring,pain will recur. -
• Hematological : erythrocyte sedimentation rate, complete • • • • • • • blood count Biochemical : C-Reactive protein , Ca level , ALP Serological : RF , ANA X- ray CT scan MRI Isotope bone scan Ultrasound
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