EXAMINATION OF THE SPINE

Spinal disease is any pathology which affects the spinal column and the spinal cord and spinal nerves which are controlled there in. Spine disease is a large area of study because of the large number of diseases which can affect the spinal system, from purely skeletal to primary nervous system disorders. All types of spine disease can present with either or both spinal symptoms and neurological symptoms associated with injury or compression of the spinal cord or spinal nerves. Spine disease is very common, with many people undergoing spinal surgery every day. The bony spine is intended so that vertebral column “stacked” together can provide a wobbly support structure. The spine also protects the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, which is a bony prominence behind the spinal cord that shields the cord’s nerve tissue. The vertebrae also have a strong bony “body” in front of the spinal cord to provide a platform suitable for weight-bearing. The discs are pads that serve as “cushions” between each vertebral body that serve to minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). With injury or degeneration, this softer component can sometimes rupture (herniate) through the surrounding outer ring (annulus fibrosus) and irritate adjacent nervous tissue. Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

History

Pain: The patient with a spinal disease usually presents with pain; which is localized to the area of involvement in the spine. In cervical spondylosis the pain is in the cervical region while the pain is felt in the lumbosacral area in prolapsed intervertebral disc, spondylolisthesis or in osteoarthritis of the spine. Tuberculosis usually involves the dorsal or dorsolumbar spine producing pain in these areas of the spine.

Pain associated with stiffness in the back, especially in the morning in a young male is often seen in ankylosing spondylosis.

Pain in the low back, exaggerated on coughing or sneezing indicates a disc prolapse.

Radicular Pain: Pain in the spine may be associated with radiating pain into the extremities. For example, in cervical spondylosis the pain may radiate to the upper limbs; low backache may be associated with pain in the lower limbs in disc prolapse or in spondylolisthesis. In tuberculosis of the dorsal spine, the pain may radiate along the intercostalnerves to the front of the trunk. This type of pain is called girdle pain.

Paraesthesia: Back pain may be associated along with tingling or numbness in the extremities in conditions like discprolapse or spondylolisthesis. Back pain with paraesthesia and radicular pain in the lower limbs on walking in characteristic of lumbar canal stenosis. In this condition the symptoms are relieved temporarily if the patient gets an opportunity to set for a few minutes in the middle of walking. He can walk again for the same distance before the symptoms reappear. It is called intermittent claudication.

Weakness in the extremities may be seen in disc prolapse, spondylolisthesis, tuberculosis or spinal cord tumour. The patient may also develop paralysis distal to the involvement in the spine.

Examination

Inspection
Gait: The gait must be observed as the patient walks into the examination room. The patient with tuberculosis of the spine walks cautinuously, allowing little movement to the spine. A patient suffering from ankylosing spondylitis walks with a stiff gait, the spine is stiff and there is no movement of the head and neck. A patient with severe disc prolapse is bent forward slightly.
The patient’s back must be exposed completely and the patient must be examined from behind. A nurse or a female attendant must accompany the doctor while examining a female patient. The patient is examined in standing and spine lying position.
Deformity: In standing position, when the patient is examined from behind, the spine is in a straight vertical line from the nape of the neck to the natal cleft. Both the scapulae are symmetrically placed at the same level. Lateral curvature of the spine with asymmetry of the scapulae occurs in scoliosis. Normally there is mild kyphosis in the dorsalspine. Exaggerated generalized kyphosis occurs in Scheuermann’s disease in children and in osteoporosis in the elderly; in young males it is seen in ankylosing spondylitis. Localized kyphosis (“knuckle” due to collapse of one vertebra, and “gibbus” due to collapse of 2-3 vertebrae) is seen in tuberculosis.

Swelling in the paraspinal region or lumbar region may be seen as a “cold abscess” in tuberculosis. A soft cystic swelling in the paraspinal region in a child is seen in spina befida manifesta (or cystica).

Palpation
Tenderness in the spine is elicited initially by giving gentle blows to spine from dorsal spine to the sacral region, with a fist. Once the tender area in the spine is identified, tenderness is then elicted by pressing the spinous process of the vertebra with the thumb. When tuberculosis is suspected the thumb is used to apply pressure over the transverse process of the vertebra (rather than the spinous process). By this manoeuvre an attempt is made to rotate the vertebra to elicit tenderness.

Movements
The movements of the spine-forward flexion lateral bending and rotation-are tested systematically. Forward flexion may be restricted in tuberculosis, disc prolapse or due to muscle spasm in postural backache. In disc prolapse the trunk lists to one side on forward flexion. Flexion is grossly restricted in ankylosing spondylitis.

Neurological Examination
Examination of the spine is not complete unless a complete neurological examination of the extremities is performed systematically.

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