Scoliosis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; AE Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]
Overview
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Physical Examination
Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.
Appearance of the Patient
- Patients with scoliosis usually appear well.
Vital Signs
Patients with scoliosis and other complications may have:
- High blood pressure due to pulmonary hypertension and cor pulmonale
Skin
- Skin for café au lait spots indicative of neurofibromatosis
- Spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma.
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
HEENT
- HEENT examination of patients with Scoliosis is usually normal.
Neck
- Neck examination of patients with scoliosis is usually normal. But, patients may have lateral bending of their neck due primary or secondary curve.
- when scoliosis is complicated with pulmonary hypertension, it's physical findings may include0.0.0:
Prominent 'a' wave: due to forced atrial contraction
- Prominent 'v' wave: later if tricuspid regurgitation develops with right ventricular failure
- Elevated JVP: can be present if right ventricular failure develops
- Postive Kussmaul's sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure
Lungs
Patients with scoliosis and other complications may have:
- Chest wall or breast asymmetry is seen
- Decrease breast sounds upon auscultation of the lung
Heart
Patients with scoliosis and it's late complications such as pulmonary hypertension and cor pulmonale include physical findings:[1][2][3]
- Left parasternal heave: due to hyperdynamic right ventricle
- Palpable P2: correlates with severity of the disease
- Ausculation
- First and second heart sound (S1,S2)
- Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.
- First and second heart sound (S1,S2)
Splitting of S2
- Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.
- Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.
- Extra Heart Sounds
- S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
- S3: if right ventricular failure develops. Increased with inspiration.
- Additional Sounds
Systolic pulmonary ejection click: increased with inspiration
- Murmurs
- Ejection midsystolic murmur: increased with inspiration
- Diastolic murmur (Graham-Steele murmur): indicates pulmonary regurgitation
- Pansystolic murmur: indicates tricuspid regurgitation and developing right ventricular failure[5]
- Murmurs
Abdomen
- Abdominal examination of patients with [disease name] is usually normal.
Back
- Back examination of patients with scoliosis is vital. Physical findings may include:
OR
- Point tenderness over __ vertebrae (e.g. L3-L4)
- Sacral edema
- Costovertebral angle tenderness bilaterally/unilaterally
- Buffalo hump
Genitourinary
- Genitourinary examination of patients with scoliosis is usually normal. But, in neuromuscular scoliosis, patient may present with bowel and bladder incontinence.
Neuromuscular (Spine)=
- Patient is usually oriented to persons, place, and time
Gait
- Patients usually walk with bipedal unassisted gait.
- Some patients with neuromuscular scoliosis walk with a spastic gait.
Palpation=
- No local rise in temperature
- Tenderness is usually not present.
- Head may be centered or tilted away from pelvis
- Shoulders asymmetry
- Scapular asymmetry with one scapula being farther away from the the mid-line
- Spinous process are deviated away from mid-line
- Lateral curvature of the spine, with curve described in terms of convexity directed to right or left
- Paraspinal muscle spasm may be present
- Rib razor hump is usually present
- Posterior Superior Iliac spine (PSIS) asymmetry seen
- Anterior Superior Iliac spine (ASIS) asymmetry seen
- List and step are usually not present
- Sagittal balance (Head in line with sacrum) may be disturbed
- Sinuses and tuft of hair may be present
- Flank fullness may be seen
Neurological
- Motor
- Motor weakness may be seen
- Spasticity and rigidity may be seen depending on level of involvement
- Sensory
- Fine touch and crude touch may be lost
- Hypoasthesia may be seen
- Postion sense and vibration may be disturbed
- Two point discrimination may be lost
- Reflexes
- Hypo or Hyper reflexia may be seen depending on level of involvement
- CLonus may be seen
- Cordination
- Cordination may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation
Measurement
- Chest expansion is usually decreased
- Schober's test is normal
- Modified schober's test is normal
- Wall to occiput distance is normal
- Single breath count test may be decreased
Special Test
- Straight leg raising (SLR) test may be positive
- Cross SLR is usually absent
- Lassegue test may be positive
- Bowstring test may be positive
- Femoral stretch test may be positive
- Altered mental status
- Glasgow coma scale is ___ / 15
- Clonus may be present
- Hyperreflexia / hyporeflexia / areflexia
- Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
- Muscle rigidity
- Proximal/distal muscle weakness unilaterally/bilaterally
- ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Positive straight leg raise test
- Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
- Positive/negative Trendelenburg sign
- Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
- Normal finger-to-nose test / Dysmetria
- Absent/present dysdiadochokinesia (palm tapping test)
Extremities
- Extremities examination of patients with [disease name] is usually normal.
OR
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
- ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
- ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.
Extremities
- Uneven hip and shoulder levels
- Unequal distance between arms and body
- The feet for cavovarus deformity
Neurologic
- Slow nerve action (in some cases)
- Abdominal reflexes
- Muscle tone for spasticity
- The patient's gait is assessed
Others
- Asymmetric size or location of breast in females
- Uneven musculature on one side of the spine
- A rib "hump" and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
- During the exam, the patient is asked to bend forward (Adam's Bend Test). If a hump is noted, then scoliosis is a possibility and the patient should be sent for an x-ray to confirm the diagnosis.