Scoliosis is a reflex reaction of the muscular apparatus. Providing giving the spine a position that contributes to the displacement of the root from the place of maximum protrusion of the disc in the opposite direction (to the right or to the left) and to reduce pain: the side of scoliosis formation depends on the localization of the disc herniation, its size, root mobility and the nature of the reserve spaces of the spinal canal. More often, there is a homolateral scoliosis, with a bulge facing the sick side, less often heterolateral (with a convexity facing the healthy side), even less often – alternating. With alternating scoliosis, the tension side of the long back muscles also changes. Heterolateral scoliosis develops when the root is located to the inside, and homolateral – to the outside of the disc herniation. Alternating scoliosis is typical for small protrusions, more often median ones, as well as for the syndrome of spinal instability. Scoliosis is accompanied by tension of the erector muscle of the back on the convex side and multiple on the concave side. It is more often angular, less often S-shaped due to the addition of compensatory curvature in the thoracic region to lumbar scoliosis.
I Yu. Popelyansky distinguishes three degrees of scoliosis:
Scoliosis occurs only during functional tests (flexion, extension, lateral bending);
It is well defined when viewed in a standing position of the patient, but is unstable and disappears when sagging on chairs and in a prone position on the stomach;
Persistent scoliosis that does not disappear when sagging on chairs and lying on your stomach.
The most pronounced degree of scoliosis is observed with lesions of the L4-L5 and L5-S1 discs. In scoliosis, a skin fold of the waist is formed corresponding to the concave side of the upper part of the lumbar scoliosis. The position of the wings of the iliac bones is also determined, since on the side of pain the wing usually drops, and on the opposite side it rises. Then the position of the pelvis is assessed. If the pelvis on one side is evenly lower, then often the patient has different lengths of the legs. In this case, neurological syndromes arise due to the unequal distribution of the axial load on both legs, indicating a violation of the patient’s statics (statics is disturbed with a difference in weight of 5 kg, which is determined using floor scales). The installation and shape of the feet are noted (flattening of the arch of the foot occurs with flat feet, which is detected when walking barefoot), the presence of an external rotation of the foot, and the installation of the knee. Pay attention to body hair in the sacrum (an indirect sign of Spina bifida); for the presence of a venous network in the sacrum and lumbo-sacral rhombus. In the standing position, you can see the tension of the superficial muscles, and in the prone position – the deep ones (the superficial muscles are turned off).
The spinous processes of the spine are usually palpated with the thumb and forefinger of the right hand. At the neck level, they are palpated in a standing position or sitting with an unbent neck, at the lower levels – in any position, but lying is better.
The articular processes at the cervical level are palpated from the back and from the side when the patient tilts the head slightly backward and towards the palpable joints, along the line from the point of the vertebral artery downward (corresponds to the C1-C2 joint). The point of intersection of this line with the horizontal line at the level of the angle of the lower jaw corresponds to the C2-C3 joint. The transverse processes and the anterior parts of the vertebral bodies, starting from the II cervical vertebra, must be palpated from the side-front. On palpation of the spinous process of C7, the patient is asked to bend back and, if the process does not disappear, then it is C7, and if it disappears, therefore, C6. It is also important to remember that the C7 vertebra is normally inactive in relation to other vertebrae of the cervicothoracic junction. Soreness of the lateral part of the spinous process indicates an increase in tension on this side, especially if rotation in the opposite direction is limited.
Palpation of the intervertebral joints, as well as the transverse processes, is best performed using the spring pressure method. The patient is located in the prone position. The doctor’s hands are extended, the index and middle fingers of one hand are paravertebrally at the level of the interspinous space of one segment (“fork” method). With the base of the palm (hypotenar) of the other straightened hand, which is on the fingers of the first, springy movements are made on the terminal phalanges. The entire spine is sequentially examined from the thoracolumbar junction from the bottom up. If there is a block, then the spring resistance is reduced.
In the area of the cervical spine, shoulder girdle and arms, the following main pain points are examined:
1) Lesser occipital nerve – at the mastoid process along the posterior edge of the sternocleidomastoid muscle.
2) The greater occipital nerve – in the middle of the line connecting the mastoid process with the 1st cervical vertebra.
3) Cervical intervertebral discs. The doctor puts his hand on the anterolateral surface of the patient’s neck, immerses the II-III fingers between the anterior surface of the sternocleidomastoid muscle and the larynx, pushes the larynx and deep soft tissues medially, feeling the anterior surface of the spine.
4) The upper point of Erb (supraclavicular) – 2-3 cm above the clavicle at the outer edge of the sternocleidomastoid muscle.
5) Naderbovskie – this is the level of the transverse processes of the vertebrae. They are located above the Erba point. The doctor stands facing the patient, puts the thumb on the anterolateral surface of the neck lateral to the sternocleidomastoid muscle above the Erb point. The radial edge of the finger moves medially between the specified muscle and the anterior tubercles of the transverse processes of the cervical vertebrae.
6) Anterior scalene muscle. Palpate over the clavicle lateral and behind the sternocleidomastoid muscle. The patient tilts his head to the affected side. The doctor pushes the clavicular portion of the sternocleidomastoid muscle inward with the middle or index finger. The patient takes a deep breath and turns his head to the healthy side.
The doctor deepens the middle and index fingers down and medially, covering the muscle. If the legs of the sternocleidomastoid muscle are widely spaced, then the lower end of the scalene muscle is probed between them.
7) Upper inner corner of the scapula. Scapular crest areas. 9) Attachment of the deltoid muscle to the shoulder – on the border of the upper and middle third of the shoulder along the outer surface, between the biceps and triceps muscles. 10) The area of the quadrilateral foramen is the exit site of the axillary nerve (along the back of the shoulder). 11) The area of the cubital canal is the place most accessible for palpation of the ulnar nerve (n. Ulnaris). 12) The pronator region of the forearm (m. Pronator teres), between the two legs of which the median nerve passes. 13) The area of the wrist (carpal tunnel), by palpation and percussion.
If the spinous processes are palpated at the thoracic level while sitting, then the maximum flexion position is required. Pay attention to the distance between the processes, their painfulness and mobility on palpation, to the same height, to deviation with divergence and standing, to the formation of depressions and irregularities between two processes in the form of free spaces, to the presence of pain in the sclerotome points and areas with muscle tension, which allows you to identify a blocked or hyper-movable segment. Normally, the spinous processes are tiled, with the exception of the T1 and T2, T9-12 vertebrae, which approach the horizontal position.
In a normal state, with a deep breath, the spinous processes move away from each other somewhat, the chest expands, and when you exhale, they approach, the chest collapses. In the presence of pain and blockage in the thoracic segment of the spine, the patient breathes shallowly and the dynamics of the respiratory excursion is absent.
Palpation of the interspinous ligaments is carried out in the patient’s sitting position in the kyphotic position, while the spinous processes diverge. Numerous periosteal pain points can be identified on the ribs, shoulder blades and sternum.
The capsules of the intervertebral joints in the thoracic spine are palpated immediately lateral to the spinous processes, the capsules of the joints of the heads of the ribs are 2-2.5 cm lateral to the spinous processes, and the tubercles of the ribs with transverse processes (5-6 cm lateral when the patient is prone or sitting) …
By palpating the ribs and intercostal spaces, one can reveal soreness, standing or retraction of the rib.
Spinous processes L4, L5, S1 are more often painful. Soreness is caused by the transfer of pressure to the degenerative disc and excessive mobility (instability) of the spinal segment.
At the lumbar level, the intervertebral joints are 2.5 cm outward from the interspinous spaces of the same name; the anterior edges of the bodies are palpated through the anterior abdominal wall.
The cross-coccygeal joint and the coccyx are examined in the position of the patient on his stomach.
The doctor, exerting pressure on the coccyx with his fingers, determines its soreness and mobility in the sagittal plane, and also determines the soreness of the muscle located deep in the muscle that lifts the anus. The coccyx is palpated with the index finger in the knee-elbow position or on the left side, with the thumb located above the coccyx. Determine the position of the coccyx, its deformation and deviation to the side. The sacrococcygeal joint and the pelvic floor muscles are also palpated: the levator anus, the coccygeal muscle above, and the piriformis muscle even higher.
The main pain points in the lumbosacral spine and lower extremities are as follows:
1) The anterior Gara point is near the midline of the abdomen at the level of the navel (corresponds to the anterior surface of the L4-L5 disc, and 3-4 cm below – L5-S1).
2) The back points of the Gar – correspond to the interspinous ligaments L4-L5, L5-S1 or paravertebrally at the level of L3-L5, as well as along the sciatic nerve.
3) A point midway between the sacroiliac joint and the posterior superior iliac spine.
4) Vallee’s points: in the middle between the ischial tuberosity and the greater trochanter, under the gluteal muscles, in the middle of the thigh, in the popliteal fossa, in the middle of the gastrocnemius muscle, behind the external condyle, behind the head of the fibula, on the sole.
5) The neurovascular bundle of the thigh – along the anterior-inner surface of the thigh.
6) The iliac crest.
7) Capsules of the sacroiliac joint. Greater trochanter of the thigh. 9) Piriformis muscle. From the upper corner of the triangle, the vertices of the corners of which correspond to the superior-posterior spine, the ischial tuberosity and the greater trochanter of the thigh, the bisector is lowered to the base and divided into three parts. The point is on the border of the lower and middle 1/3 of this line. 10) Obturator – between the ischial tuberosity and the edge of the lower part of the sacrum. 11) The exit of the lateral cutaneous nerve of the thigh is 10 cm below the anterior superior iliac spine. 12) Anterior part of the capsule of the hip joint – 2 fingers below the anterior lower spine of the ilium. 13) Adductor longus femoris – in the middle or in the upper third muscle. 14) The inner edge of the middle 1/3 of the biceps femoris. 15) The external and internal heads of the triceps muscle of the leg – in the popliteal fossa. 16) Anterior tibial point – in the middle of the upper 1/3 of the antero-outer surface of the lower leg. 17) Peroneal – behind and below the head of the fibula. 18) The inner edge of the soleus muscle – anterior to the inner head of the gastrocnemius muscle, in its upper half. 19) Birbrair’s Achilles point – at the junction of the triceps muscle of the lower leg in the indicated tendon (often painful when the S1 root is affected).
Turgor and trophism of tissues, elasticity, soreness, severity and persistence of local dermographism in palpation sites are assessed, trigger zones, edema, and changes in skin temperature are detected.
Functional blockage in the spine is determined by skin turgor (Kibler’s fold). A fold of skin is grasped by the doctor’s two hands in the area of the thoracolumbar junction,
retreating from the line of spinous processes by 4-5 cm and the tips of the thumbs are “sliding” along the paravertebral lines in the cranial direction, at this time the skin is folded with the index fingers. Where there is a blockage, the skin turgor is increased and the fold slips out of the doctor’s hands. This technique also reveals sensory disorders in the form of hyperalgic zones.
General clinical (palpation, myotonometry, dynamometry) and special neuro-orthopedic techniques are used to judge the state of the muscular system.
General clinical and special neuro-orthopedic techniques
Reflex sphere studies
First, the metacarpal-radial reflexes are examined, then the elbow flexion and extension reflexes. When the muscles are relaxed, a short, jerky blow is applied to the tendon or periosteum.
The elbow flexion reflex is caused by a blow to the biceps tendon, first one and then the other of the patient’s arm. Flexion-ulnar and scapular-humeral (ankylosing spondylitis) reflexes change with pathology of the C5-C6 roots.
The elbow extensor reflex is determined by striking the triceps tendon with a hammer. In this case, the forearm and hand should hang freely with complete relaxation of the muscles. The elbow extensor reflex changes in the pathology of the roots C7-C8.
The metacarpal-ray reflex is triggered by striking the radius of the hammer at the styloid process. In this case, flexion of the arm in the elbow joint, slight pronation and flexion of the fingers occurs. This reflex changes when the C5-C8 roots are affected.
Abdominal reflexes are triggered when the stroke is directed from the periphery of the abdomen to the midline.
The upper abdominal reflex is caused by a stroke parallel to the lower edge of the costal arches and corresponds to segments D7-D8, the middle one – by a stroke along the horizontal line at the level of the navel and corresponds to segments D9-D10 and the lower one – is caused by a stroke parallel to the inguinal folds and corresponds to segments D11-D12.
The cremasteric reflex is caused by streak irritation of the skin of the inner surface of the thigh and corresponds to segments S1-S2.
The knee reflex is investigated by striking the patellar ligament with a hammer, preferably in the supine or sitting position. It decreases when the L2-L4 roots are affected.
The Achilles reflex is examined by striking the Achilles tendon with a hammer. Decreases or disappears when the S1 root is affected.
In conclusion, the data obtained by questioning the patient and objective research are synthesized, syndromological diagnostics, differential diagnosis are carried out and additional X-ray, electrophysiological and other studies are planned to clarify the clinical diagnosis.