🩺 Orthopedic Exam Guide (Part 4 - The Spine)

1. The Back & Deformities

Clinical Examination of the Back
  • Symptoms:
    • Pain: Back pain, or referred pain (sciatica) down the limb. Root dura pain is intense with numbness. Joint/ligament pain is inconstant without neuro symptoms.
    • Stiffness: Sudden (disc prolapse) or continuous/worse in morning (ankylosing spondylitis).
    • Deformity: Kyphosis or Scoliosis.
    • Numbness/Paraesthesia: If aggravated by standing/walking and relieved by sitting -> suggests Spinal Stenosis.
  • Examination (Standing):
    • Look: Posture, level pelvis, leg length, scars, kyphosis (forward curve), lordosis (backward curve).
    • Feel: Spinous processes and interspinous ligaments.
    • Move: Flexion, Extension (The 'wall test' unmasks disguised loss of extension), Lateral flexion, Rotation. Muscle power (tiptoes for plantar flexion, heels for dorsiflexion).
  • Examination (Prone & Supine):
    • Prone: Bony outlines, deep tenderness. Femoral stretch test (bending knee with hip flat; positive if pain in front of thigh -> lumbar root tension).
    • Supine: Straight-leg raising test (classic for lumbosacral root tension; positive if pain in buttock/back before 90 degrees). Neurological exam is essential.
Scoliosis
  • Definition: Sideway curvature of the spine.
  • 1. Postural Scoliosis: Secondary to outside conditions (e.g., short leg). Disappears when sitting or flexing. 'Sciatic scoliosis' is due to muscle spasm from disc prolapse.
  • 2. Structural Scoliosis: Fixed, accompanied by bony abnormality/rotation. Does not disappear on posture change. Types:
    • Idiopathic: Most common. Adolescent presents before puberty.
    • Osteopathic: Congenital vertebral anomalies.
    • Neuropathic: Asymmetrical muscle weakness (Polio, CP).
    • Myopathic: Muscular dystrophies.
  • Adolescent Idiopathic Scoliosis:
    • Vertebrae rotate (bodies point to convexity, spinous processes to concavity). Ribs on convex side form a prominent hump.
    • Looks worse on flexion (unlike postural).
    • X-Ray: Full-length views to measure Cobb's angle. Check Risser's sign (ossification of iliac apophysis from 1 to 5) to assess skeletal maturity.
  • Treatment of Scoliosis:
    • Exercises alone have no effect on the curve.
    • Bracing: For progressive curves (20-40 degrees). Milwaukee brace (worn continuously with 1 hr break/24hr). Boston brace (for curves below T9).
    • Surgery: If curve > 40 degrees, balanced double curve > 60, or significant deterioration. Aim: straighten via instrumentation and arthrodese (fuse).
Kyphosis & Scheuermann's Disease
  • Kyphosis vs Kyphos (Gibbus): Kyphosis is excessive dorsal curvature. Kyphos is sharp posterior angulation (due to collapse/fracture/TB).
  • Types: Postural (round back, drooping shoulders) vs Structural (osteoporosis, Ankylosing spondylitis, Scheuermann's).
  • Scheuermann's Disease (Adolescent Kyphosis):
    • Developmental disorder of growing spine (irregular ossification/fragmentation of vertebral body epiphyses).
    • More common in boys starting at puberty.
    • Clinical: Smooth thoracic kyphosis that does not improve with posture.
    • X-Ray: Patchiness, irregularity of end plates, vertebral bodies become wedge-shaped.
    • Treatment:
      • < 40 degrees: Exercise.
      • 40 – 60 degrees: Brace (extension brace for 1-1.5 years).
      • 60 – 80 degrees: Posterior fusion.
      • > 80 degrees: Posterior & Anterior fusion.
💡 Golden Hints

1. Postural vs Structural Scoliosis: Postural scoliosis disappears when the patient sits or bends forward. Structural scoliosis looks worse on forward flexion due to vertebral rotation.

2. Risser's Sign: A vital radiological sign (grading ossification of the iliac apophysis 1 to 5) used to assess skeletal maturity. It helps determine if a scoliosis curve will continue to progress.

3. Diagnostic Tests for Back Pain: The Femoral stretch test evaluates upper lumbar root tension (pain in front thigh), while the Straight-leg raising test evaluates lower lumbosacral root tension (pain in buttock/back).

2. Injuries of the Spine

Spinal Stability & General Principles
  • Double Threat: Damage to vertebral column + neural tissues.
  • The 3 Columns of Stability (Denis):
    • Anterior column: Anterior half of body, annulus, and Anterior Longitudinal Ligament (ALL).
    • Middle column: Posterior half of body, annulus, and Posterior Longitudinal Ligament (PLL).
    • Posterior column: Pedicles, facet joints, posterior arch, inter/supraspinous ligaments.
    • Rule: Fractures involving the middle column + at least one other are unstable.
  • Level of Spinal Injury: Neurological level is the lowest segment with normal function.
    • C2-C7: add +1 for cord level. T1-T6: add +2. T7-T9: add +3.
    • T10 = L1, L2 level. T11 = L3, L4 level. L1 = sacro-coccygeal.
Spinal Cord Syndromes & Medical Management
  • 1. Anterior Cord Syndrome: Flexion rotation. Compression of anterior spinal artery. Loss of power, pain, and temp below lesion.
  • 2. Posterior Cord Syndrome: Hyperextension. Loss of proprioception and vibration sense (severe ataxia).
  • 3. Central Cord Syndrome: Older age + cervical spondylosis + hyperextension. UMN lesion to legs (spastic), LMN to arms (flaccid).
  • 4. Brown Sequard's Syndrome: Hemisection of cord (stab wound). Uninjured side has good power but absent pinprick/temp.
  • 5. Cauda Equina Syndrome: Lower motor neuron lesion causing flaccid paralysis.
  • Medical Management (Methylprednisolone): High-dose steroid given within 8 hours after injury. 30 mg/kg IV bolus, then 5.4 mg/kg/hour for 23 hours. Improves recovery by ~20%.
  • Spinal Shock: Temporary failure of cord (flaccid paralysis, absent reflexes). Lasts < 48hrs. Return of primitive reflexes (anal wink, bulbocavernosus) marks the end of spinal shock.
Cervical & Thoracolumbar Fractures
  • C1 - Jefferson's Fracture: Axial load on top of head. Fractures the ring of the atlas. Seen on open-mouth X-ray view. Stable -> rigid collar. Unstable -> Halo/traction.
  • C2 - Hangman's Fracture: Fracture of C2 pedicles + torn C2/3 disc. Extension + distraction mechanism (or hitting dashboard). Treat with collar or traction/fusion.
  • Odontoid Process Fractures:
    • Type 1: Avulsion of tip. (Rigid collar)
    • Type 2: Fracture through junction of peg & body. (Halo-vest or traction/fixation)
    • Type 3: Fracture into the body of C2. (Halo-vest or traction)
  • C3-T1 Fracture-Dislocations: Flexion-rotation. Unilateral facet displacement is stable (Closed reduction + Halo). Bilateral facet dislocation is highly unstable (Urgent reduction + Halo or Surgery).
  • Thoracic & Lumbar Injuries:
    • Wedge-compression: Hyperflexion (T11, T12). Common in osteoporosis. Anterior column only (Stable). If height reduced > 50% -> Surgery.
    • Burst Injury: Severe axial compression. Explodes body, damaging middle/posterior columns (Unstable). Bone fragments may compress canal.
💡 Golden Hints

1. Golden Window for Steroids: Methylprednisolone can improve neurological recovery by ~20% in spinal cord injuries, but it must be administered within 8 hours of the injury.

2. Spinal Shock vs Cord Transection: Spinal shock causes temporary flaccid paralysis. You cannot determine the final extent of a cord injury until spinal shock ends, which is indicated by the return of the bulbocavernosus and anal wink reflexes.

3. Cervical Fractures Memory Trick: Jefferson fracture involves C1 (atlas ring burst). Hangman's fracture involves C2 (axis pedicles).

3. Spondylolisthesis & Infections

Spondylolysis & Spondylolisthesis
  • Definitions:
    • Spondylolysis: A break in the pars interarticularis.
    • Spondylolisthesis: Forward displacement of one vertebra over another (usually L4 on L5, or L5 on S1).
  • Classification (6 Types):
    • Type I Congenital (Dysplastic): Agenesis of superior articular facet. Children, painless, protruding abdomen.
    • Type II Isthmic (Lytic): Pars defect. Commonest. Adults, intermittent backache, step felt, flat buttocks.
    • Type III Degenerative: Women > 40, long-standing backache, secondary to facet arthritis.
    • Type IV Traumatic: Fracture/dislocation not involving the pars.
    • Type V Pathologic: Destructive disease (malignancy, TB).
    • Type VI Iatrogenic: Post-surgical (aggressive laminectomy).
  • Grading (Amount of Slip):
    • GI (< 25%), GII (26-50%), GIII (51-75%), GIV (76-100%), GV (> 100% - Spondyloptosis).
  • Treatment: Conservative (Physical therapy, Thoracolumbosacral orthosis/brace for 3-6 months for slip < 50%). Operative (Spinal fusion) if symptoms disabling, neuro compression, slip > 50% in immature, or failure of 9-12m conservative therapy.
Spinal Stenosis & Backache Patterns
  • Spinal Stenosis: Narrowing of canal due to hypertrophy of posterior disc margin and facet joints. Aging process.
    • Classification: Central canal vs. Lateral recess. Primary (Congenital) vs. Secondary (Acquired/Degenerative).
    • Clinical: Chronic pain, Neurogenic Claudication (pain/numbness after walking 5-10 mins, relieved by sitting/squatting/flexion).
    • Imaging measurements: Mid-sagittal (< 15mm plain film, < 11mm CT) or Interpedicular (< 20mm plain, < 16mm CT).
    • Treatment: Conservative (posture, NSAIDs). Operative (Decompression/Laminectomy) if incapacitating. Warning: surgery relieves neuro symptoms but may not cure backache.
  • The Backache Problem (5 Patterns):
    1. Transient backache: Muscular strain.
    2. Sudden acute pain + sciatica: Under 20 (exclude infection/spondylolisthesis), 20-40 (disc prolapse), elderly (osteoporotic wedge).
    3. Chronic low back pain: Over 40, recurrent (facet dysfunction, osteoarthritis).
    4. Back pain + pseudoclaudication: Over 50 (Spinal stenosis).
    5. Severe constant pain: Bone pathology (Infection, tumor, Paget's).
Tuberculosis & Pyogenic Infections
  • Tuberculosis of Spine (Pott's Disease):
    • Most common/dangerous site of skeletal TB. Starts in vertebral body -> spreads to disc -> destruction -> sharp angulation (Gibbus) + Cold Abscess.
    • Clinical: Constitutional symptoms (fever, weight loss), chronic backache.
    • Pott's Paraplegia: Cord compression. Early-onset (pressure from abscess/sequestrum -> decompress). Late-onset (increasing deformity/vascular insufficiency).
    • Diagnosis: Tissue biopsy/culture for AFB. ESR is markedly elevated.
    • Treatment: Anti-TB drugs for 6-12 months. Surgery if abscess, marked destruction, or threatened paraplegia.
  • Pyogenic Infection (Discitis/Spondylitis):
    • Usually Staphylococci. Severe pain, acute muscle spasm.
    • X-Ray: Narrowing disc + destruction. Late cases show new-bone formation (distinguishes it from TB).
    • Treatment: Bed rest + IV antibiotics for 4-6 weeks.
💡 Golden Hints

1. Neurogenic Claudication: The hallmark of Spinal Stenosis is pain or numbness in the legs after walking 5-10 minutes that is consistently relieved by sitting, squatting, or spinal flexion.

2. TB vs Pyogenic Spine: Pyogenic spondylitis is usually caused by Staphylococci and uniquely shows new-bone formation in late stages, which distinguishes it from spinal Tuberculosis (which causes pure destruction/caseation).

3. Isthmic Spondylolisthesis: This is the most common variety (Type II). It occurs due to a defect in the pars interarticularis, often presenting with a "step" felt on the spine and curiously flat buttocks.

4. Intervertebral Disc Lesions

Prolapsed Intervertebral Disc & Sciatica
  • Pathology: Nucleus pulposus squeezes through annulus fibrosus, bulging beneath posterior longitudinal ligament. Compression causes backache (ligament), sciatica (root dura), or numbness/weakness (nerve root). Most common at L4/5 and L5/S1.
  • Clinical Features: Young adult, sudden pain after lifting/stooping. Sciatic scoliosis (list to one side). Worsened by coughing/straining.
    • Straight-leg raising test is limited/painful.
    • L4 Root: Weakness in lifting the foot (Foot drop).
    • L5 Root: Weakness of big toe extension and knee flexion, numbness on outer leg / dorsum of foot.
    • S1 Root: Weakness of calf/outer ankle (plantar-flexion/eversion), depressed ankle jerk, numbness on lateral border of foot.
    • Cauda Equina Compression: Urinary retention + sacral numbness (Saddle anesthesia). Surgical emergency!
  • Imaging & Differential: MRI/CT best for locating lesion. Exclude inflammatory (ankylosing spondylitis), tumors (constant pain), and nerve tumors.
Management (The 4 Rs) & Segmental Instability
  • Treatment of Disc Prolapse (4R):
    1. Rest: Bed rest, hips/knees flexed, anti-inflammatory drugs.
    2. Reduction: Bed rest + traction for 2 weeks reduces 90% of cases. Epidural steroid injections.
    3. Removal (Surgery): Indications include: Cauda equina syndrome (within 6 hrs), persistent pain > 2 weeks despite conservative rx, neuro deterioration, frequent recurring attacks. Procedures: Laminectomy/Discectomy.
    4. Rehabilitation: Isometric exercises, correct posture, avoid heavy lifting.
  • Lumbar Segmental Instability & Osteoarthritis:
    • Flattening of disc -> facet joint displacement and secondary osteoarthritis.
    • Clinical: Over 40 yrs, intermittent backache related to physical work/prolonged standing. Relief on lying down. 'Locking' or 'giving way' incidents. Difficult straightening up from forward bending.
    • X-Ray: Narrowed disc space, marginal osteophytes.
    • Treatment: Conservative (corset, NSAIDs, modifying activity). Surgery (fusion) if severe.
💡 Golden Hints

1. Surgical Emergency: Cauda equina compression syndrome (characterized by urinary retention and sacral sensory loss) is an absolute emergency requiring surgical decompression within 6 hours.

2. Root Localization Rule: Loss of ankle jerk = S1 root. Weakness of big toe extension = L5 root. Foot drop = L4 root.

3. The 4 Rs of Disc Herniation: Management logically follows: Rest -> Reduction (Traction/Steroids) -> Removal (Laminectomy if failure) -> Rehabilitation.

5. High-Yield Comparisons (المقارنات الامتحانية)

إليك أهم المقارنات المستخلصة من ملازم العمود الفقري والتي تتردد باستمرار في الأسئلة:

1. Spinal Stenosis vs. Disc Herniation
Feature Spinal Stenosis Disc Herniation
Age Usually > 50 years Usually < 50 years
Onset Insidious (gradual) Sudden (acute after lifting)
Sitting (Flexion) Better (relieves pain) Worse (aggravates pain)
Extension Worse (aggravates pain) Better (relieves pain)
Dural Tension Signs (e.g., SLR) Less Common Common
2. Postural vs. Structural Scoliosis
Feature Postural Scoliosis Structural Scoliosis
Etiology Secondary to outside conditions (e.g., short leg, muscle spasm). Primary bony abnormality or vertebral rotation.
Effect of Posture Change Disappears when sitting or flexing. Does not disappear, fixed.
Forward Flexion Test Curve straightens out. Looks worse (rib hump stands out).
3. Incomplete Spinal Cord Syndromes
Syndrome Mechanism Clinical Deficit
Anterior Cord Flexion rotation (anterior artery compression) Loss of power, pain, and temperature below lesion.
Posterior Cord Hyperextension (posterior body fracture) Loss of proprioception and vibration sense (severe ataxia).
Central Cord Hyperextension in elderly with cervical spondylosis UMN lesion to legs (spastic), LMN to arms (flaccid).
Brown-Séquard Hemisection of the cord (e.g., stab injury) Good power but absent pinprick/temperature on uninjured side.
4. Tuberculous vs. Pyogenic Spondylitis
Feature Tuberculosis of Spine (Pott's) Pyogenic Infection
Onset & Course Chronic, insidious (months). Acute, severe pain & muscle spasm.
Pathology Caseation, cold abscess, marked destruction. Pus formation, acute inflammation.
X-Ray Healing Sign Pure destruction with sharp kyphos (Gibbus). New-bone formation in late cases.
5. Nerve Root Compression Signs (Lumbar)
Root Motor Weakness Reflex Change Sensory Loss
L4 Lifting the foot (Foot drop) Decreased Patellar (knee) jerk Medial leg
L5 Big toe extension, knee flexion Increased Knee reflex (often normal ankle) Outer side of leg & dorsum of foot
S1 Plantar-flexion / eversion (Calf muscles) Depressed Ankle jerk Lateral border of the foot