The physical examination should begin with observing the patient in the sitting and standing positions from the back as well as the front. Observing the patient moving around, dressing, and undressing may also help in confirming the severity of the symptoms. Muscle spasms, swellings, deformities, unusual markings, redness, and hair patches should be noted. The patient's posture and gait should be observed. The area palpated includes soft tissues and bone structures for tenderness and swellings. It helps to isolate the level of the lesion. ROM should be observed. A thorough neurologic examination should be performed to assess for sensations, deep tendon reflexes, and muscle strength. Examining the
Anterior longitudinal ligament
Figure 31-10 Supporting ligaments of the spine. (Redrawn from Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 242.)
1. Degrees of inclination of trunk (note reversal of lumbar curve)
2. Level of fingertips to leg
3. Distance between fingertips and floor
Figure 31-11 Methods of measuring flexion. A, Flexion, zero starting point. B, Measuring flexion. C, Extension. D, Lateral bend. (Redrawn from CarrAJ, Harnden A.
Orthopedics in Primary Care. Boston, Butterworth-Heinemann, 1997, p 70.)
Table 31-2 Normal Range of Movement: Thoracolumbar Spine rectal tone, perineal sensations, and reflexes is essential if the patient has significant nerve root pain and weakness and chord compression is suspected.
Special tests are done for determining nerve root impingement. The straight-leg raise test is performed with the patient lying on the back on the examination table. Passive lifting of the leg with the knee extended produces pain radiating down the posterior or lateral aspect of the leg, distal to the knee and often into the foot. Dorsiflexion of the foot (Lasegue's test) will increase these symptoms (Fig. 31-12). The bowstring sign is performed after a straight-leg raising test by flexing the knee to reduce radicular pain. Compression is then applied to the popliteal fossa. Return of radicular pain is considered a positive sign (Fig. 31-13). Crossed straight-leg raise is done by performing a straight-leg raise of the unaffected extremity. If the symptoms are produced on the affected extremity, the test is positive for central disk herniation. Femoral nerve traction test aids in the diagnosis of disk herniation that affects the upper lumbar spine (L2, L3, and L4). The patient lies on the stomach on the examination table with the knee flexed to 90 degrees. The physician then extends the patient's hip by lifting it off the table (Fig. 31-14). The test is positive if it produces radicular pain.
The peripheral pulses are palpated, and any abnormalities in the vascular status of the extremities are noted.
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