thoracic and lumbar spine-1.pptx

Dpt

1. Thoracic and Lumbar Spine Clinical Evaluation

2. Clinical Evaluation History: Location of Pain: Pain radiating into extremities Peripheral paresthesia or numbness: Result of impingement or pressure on nerve root exiting intervertebral foramen or dural irritation proximal to pain site Pain Locations: Lumbar pain – possible ambiguous cause Sacroiliac pathology – pain around PSIS or radiating pain in hip/groin Piriformis spasm – symptoms of sciatic nerve dysfunction

3. Clinical Evaluation

4. Clinical Evaluation History: Onset of Pain: Acute Chronic Insidious pain onset Note: Patient may describe a single incident that initiated pain, although trauma is probably an accumulation or repetitive stresses/microtrauma

5. Clinical Evaluation History: Mechanism of Injury: Movement: Flexion, Extension, Lateral Bending, Rotation Blunt Trauma: Direct blow to lumbar/thoracic area Contusions Compressive Stress: Hyperextension of spine

6. Clinical Evaluation History: Pain Consistency: Constant Pain: Unyielding (does not improve with various position of patient’s spine) Example pathology – Inflammation of dural sheath

7. Clinical Evaluation History: Pain Consistency: Intermittent Pain: Mechanical Origin – certain spinal positions may ↑ or ↓ pain symptoms Compression/stretching of nerve root – Increase pain Positioning (flexion, traction) – lessen the pressure on involved structure

8. Clinical Evaluation History: Bowel or bladder signs: Does the patient have any bowel or bladder problems? Incontinence: Loss of bowel or bladder control May indicate lower nerve root lesions (cauda equina syndrome), or spinal cord injury Description: urinary incontinence may range from occasionally leaking urine (during cough/sneeze) to having sudden episodes of strong urinary urgency

9. History: Bowel or Bladder Signs: Cauda Equina Syndrome: Nerves within the spinal canal have been damaged Result: nerves supplying the muscles of the legs, bladder, bowel and genitals do not function properly Patients experience numbness, loss of sensation and pain in the legs, buttocks and pelvic region (damage usually permanent) Causes: Spina bifida (abnormality in closure of spinal canal) Tumors Injury (spinal fractures) Intravertebral disc herniation Vascular (blood vessel) problems or infections of the cauda equina

10. Clinical Evaluation History: History of spinal injury: Previous injuries: Structural degeneration Predisposition to injury Changes in activity: Exercise habits (intensity levels, duration, frequency) Footwear, running surfaces New bed

11. Clinical Evaluation General Inspection: Frontal Curvature: Alignment of lumbar, thoracic, cervical vertebrae with patient lying prone or standing Normal alignment – straight Abnormal alignment: Scoliosis – lateral curvature (lumbar and/or thoracic spine)

12. Clinical Evaluation General Inspection: Scoliosis Signs and symptoms: Uneven shoulders One shoulder blade appears more prominent Uneven waist / 1 hip higher vs. other Leaning to one side Back pain and difficulty breathing (severe scoliosis) Causes: Idiopathic (85% of cases) Underlying neuromuscular disease, leg-length discrepancy, birth defect, fetal development (congenital) Not caused by poor posture, diet, exercise, or the use of backpacks

13. Clinical Evaluation Diagnosis: Angle: X-ray Normal Spine (0 degrees) Scoliosis: (> 10 degrees) Complications: (severe scoliosis) Lung and heart damage: compression of rib cage against heart, lungs > 70 degrees Back problems

14. Clinical Evaluation General Inspection: Scoliosis Test: Adam’s Forward Bend Test Patient Position: Standing with hands held in front (arms straight) Evaluation Procedure: Patient bends forward, sliding hands down the front of each leg Positive Test: Asymmetrical hump along lateral aspect of thoracolumbar spine One shoulder blade appears more prominent Uneven hips Implications: Functional scoliosis: scoliosis present when patient stands straight, disappears during flexion Structural scoliosis: present during both standing and with flexion

15. Clinical Evaluation

16. Clinical Evaluation General Inspection: Sagital Curvature: Normal Alignment: Lordotic cervical Kyphotic thoracic Lordotic lumbar Kyphotic sacral

17. Clinical Evaluation

18. Clinical Evaluation General Inspection: Observation of GAIT: Spinal pain – influence on walking and running gait Slouching Shuffling Shortened gait Walking on tip toe – S1 weakness Walking on heels – L5 weakness

19. Clinical Evaluation General Inspection: Skin Markings: presence of darkened areas of skin pigmentation Normal Collagen disease

20. Clinical Evaluation General Inspection: Breathing patterns: Irregular breathing (i.e. shallow respirations, pain) Injury to thoracic vertebrae Pressure on thoracic nerves Trauma to ribs, costal cartilage

21. Clinical Evaluation General Inspection: Kyphosis: Abnormal forward rounding of the upper back (> 40 to 45 degrees) Round back or hunchback Causes: Developmental problems, degenerative diseases (arthritis), osteoporosis with compression fractures, trauma Severe cases: Can affect lungs, nerves, causing pain and other problems

22. Clinical Evaluation General Inspection: Kyphosis Test: Forward bend test Patient bends forward from the waist views the spine from the side With kyphosis, the rounding of the upper back may become more obvious in this position Postural kyphosis – the deformity corrects itself when patient lies on their back

23. Clinical Evaluation Postural kyphosis: May improve on its own Exercises to strengthen back muscles, correct posture, and sleeping on a firm bed Structural kyphosis: Caused by spinal abnormalities Scheuermann's disease: Developmental disorder that causes a stooped forward or bent-over posture Affects between 0.5% and 8% of the general population Osteoporosis-related kyphosis: Multiple compression fractures Low bone density

24. Clinical Evaluation

25. Clinical Evaluation General Inspection: Movement and Posture: Poor posture (standing, sitting, bending) Lordotic Curve: Reduction: Muscle spasm Hamstring tightness Increased: Hip flexor tightness Abdominal weakness

26. Clinical Evaluation

27. Clinical Evaluation General Inspection: Standing Posture: Lateral shift in trunk and pelvis Nerve root impingement (lateral shift ↓ pressure) Erector Spinae Muscle Tone: Unilateral hypertrophy or atrophy

28. Clinical Evaluation Palpation: Thoracic Spine Spinous Processes Supraspinous Ligaments: Fills space between the spinous processes Costovertebral Junction: Articulation between ribs and thoracic vertebrae Trapezius: Origin to insertion Rhomboids and levator scapulae lie deep to middle/upper traps Paravertebral Muscles Scapular Muscles

29. 1 – Spinous Processes 2 – Supraspinous Ligaments 3 – Costovertebral Junction 4 – Trapezius 5 – Paravertebral Muscles 6 – Scapular Muscles

30. Structure Landmark Cervical vertebral bodies Same level as spinous processes C1 transverse process One finger’s breadth inferior to mastoid process C3-C4 vertebrae Posterior to hyoid bone C4-C5 vertebrae Posterior to thyroid cartilage C6 vertebrae Posterior to cricoid cartilage; moves during flexion and extension of cervical spine C7 vertebrae Prominent posterior spinous process T1 vertebrae Prominent protrusion inferior to cervical spine T2 vertebrae Posterior from jugular notch of the sternum T3 vertebrae Even with the medial border of the scapular spine T7 vertebrae Even with the inferior angle of the scapula L3 vertebrae Posterior from the umbilicus L4 vertebrae Level with the iliac crest L5 vertebrae Typically demarcated by bilateral dimples, but variable from person to person S2 At level of the posterior superior iliac spine

31. Clinical Evaluation C7 T1 T2 T3 T4 T5

32. 1 – Spinous Processes 2 – Step-off Deformity 3 – Paravertebral Muscles

33. Clinical Evaluation Spondylolisthesis: Forward slippage of a vertebrae on the one below it L4 and L5 / L5 and S1 Affects 5-6% of males, 2-3% of females Causes: Strenuous physical activity (weightlifting, gymnastics, football) Types: Developmental: May exist at birth, or may develop during childhood (generally not noticed until later in childhood/adult life) Acquired: Degeneration: caused by the daily stresses that are put on spine (i.e. carrying heavy items, physical sports) Connections between the vertebrae weaken Single or repeated force

34. Clinical Evaluation Spondylolisthesis: Grade 1: 25% of vertebral body has slipped forward  Grade 2: 50% Grade 3: 75% Grade 4: 100% Grade 5: Vertebral body completely fallen off (i.e.,spondyloptosis)

35. Clinical Evaluation Symptoms: May be asymptomatic Low back pain (especially after exercise) ↑ lordosis Pain/weakness in one or both legs ↓ ability to control bowel/ bladder functions Tight hamstrings Advanced spondylolisthesis: changes may occur in the way patient stands/walks