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1 L-Spine Clinical Examination Cyriax 정형의학연구회김일환
2 Things to Remember 요통의 90% 는 Disc 가 dura 를압박해서통증이생긴다 치료는 reducible 한경우는 manipulation 이나 traction 을하고 irreducible 한경우에는 epidural block 을시행한다
3 Things to Remember Disc protrusion 은대부분 L4-5(L4 disc) 와 L5-S1(L5 disc) 사이에발생하는데, L4 disc 는 L4 nerve root( 외측으로발생시 ) 과 L5 nerve root( 내측으로발생시 ) 을압박할수있고, L5 disc 는 L5 nerve root 과 S1 nerve root 을압박할수있다. 그러므로 L4 nerve root 증상의원인은 L4 disc lesion 이고 L5 증상은 L4 or L5 disc lesion, S1 증상은 L5 disc lesion 이원인이다
4 Things to Remember 상부요추신경증상이나 S4 증상 ( 마미총증후군 : 양측하지통, 회음부마비, 대소변장애 ) 은 disc protrusion 보다는심각한병변 ( 전이암, 거대중앙탈출증 ) 을먼저생각하고 MR 등의정확한검사가필요하다
5 Exam Inspection Functional Exam
6 Inspection bony signs articular signs dural signs root signs (mobility, conduction) cord signs
7 Inspection Bony Sign angular kyphosis; ; compression Fx round kyphosis; Scheuermann s Ds shelf; spondylolisthesis Pelvic Tilt; LLD
8 Inspection Lateral deviation away; shoulder type protrusion into; axilla type alternating; small midline positional change; +small protrusion -large protrusion painful arc; small protrusion L4 disc protrusion 시에 L5 보다 deviation 심하다 Protrusion 에의한 deviation 시어깨높이는같다
9 Functional Exam 순서 Standing->Supine >Supine->Prone>Prone 1. Standing; 5 basic tests active Ext->both side Flx->Flx with neck Flx->standing on tiptoe(s1,2) look for pain(change) ) & ROM
10 FAP LOM of Ext=both side Flx 70 세 ; DJD 30 세 ; AS PAP disc protrusion with PA; favourable sign for reduction 주의 FAP 는 DJD 를먼저생각굴곡시요추전만이유지되면심각한골질환의심
11 Manipulation 보다견인치료를해야하는경우 (nuclear protrusion 가능성 ): 신전이나측굴시허리보다다리가더아플때 통증 side 로측굴시요통이더심해질때
12 모든동작에통증이없으면연관통 ( 내부장기병변 ) disc 가이미 reduction 된경우 spondylolisthesis 에의한통증 Bruised dura or nerve root 가능성 -경막외마취로치료
13 2. Supine SI distraction->(bilateral) SLR with neck flx->passive hip flx and rot->motor(r hip flx(l2,3) L2,3)->R foot dorsiflx(l4)->r great toe Ext(L4,5)->R eversion(l5,s1)- >sensory->knee >knee jerk(l3,4)- >Babinski(cord compression)
14 SI distraction 양성 ( 일측성의둔부통증 ) 일때하는 SI test Ant. SI lig test hip lat. Rot patrick s R hip adduction Post. SI lig test iliac crest compression hip med rot axial pressure on the knee R hip abduction Yeoman s(prone s(prone) Gaenslen s(supine s(supine)
15 SLR test Interpretation of SLR. Negative : a minor disc protrusion is still possible. Painful, not limited : the protrusion cannot be large. Painful arc : again a small protrusion, with dura or nerve root catching against it and sliding over it. Painful, limited, without neurological deficit : a somewhat larger protrusion, interfering with mobility, not with conduction. Painful, limited, with neurological deficit : severe compression,, not only of the dural sleeve about the nerve root, but also of the parenchyma. Both mobility and conduction are disturbed. Negative with neurological deficit :ischaemic: root atrophy limited without pain : root adhesions neck flexion at the end of straight-leg raising eases the pain, the protrusion probably lies at the axilla of the nerve root. Neurological deficit means irreducible disc; No manipulation or traction,epidural block is Tx choice
16 Neck Flx 시통증증가하면 SI joint 문제나 Hamstring 문제를제외한다 Painful arc 를염두에두어야한다 2 level 이상의 neurological deficit 이있으면 disc protrusion 가능성은희박
17 3.Prone ankle jerk(l5,s1,2)->r knee Flx(S1,2) /Ext(L3)->P knee flx(l3)->gluteal contraction(s1,2)->palpation and extension pressure on the spinous processes
18 5 보조검사 언제근육문제가의심될때외상과관련있을때 ( 횡돌기골절의심 ) 심리적원인을배제할수없을때 서서저항성양측굴검사 엎드려서 active/resistive/passive ext
19 . 감사합니다
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