Diagnosis of osteochondrosis: general examination

A general examination is carried out according to a specific plan: first, the general condition of the patient is assessed based on his state of consciousness, the position of the set of external features of his build, height and type of constitution, posture and gait. Then, the skin, subcutaneous tissue, lymph nodes, trunk, limbs and muscular system are examined sequentially.

A general examination also provides an idea of the patient’s mental state (apathy, agitation, changes in gaze, depression, etc.).

The patient's position during examination can be assessed as active, passive and forced.

An active position is one that is voluntarily chosen by the patient without visible limitations.

A passive position indicating the severity of the disease or injury is observed in severe bruises, paresis and paralysis. In such passive positions, a certain pattern can be established, typical for each injury or disease.

As an illustration, we present the following observations:

• In case of paralysis of the ulnar nerve, the fingers of the hand are hyperextended at the main phalanges, the IV and V fingers are bent at the interphalangeal joints. The flexion of the V finger is more pronounced than that of the IV.
• In case of radial nerve paresis, the hand hangs down, settling into a position of palmar flexion. The fingers are lowered, and their movements are possible only in the direction of further flexion.

The forced position due to diseases or injuries of the musculoskeletal system can extend to the entire body (general stiffness, for example, in Bechterev's disease, in severe forms of cerebral palsy, etc.) or be limited to smaller areas, capturing individual segments. Two types of such positions should be distinguished:

• forced position caused by pain syndrome (gentle position). In these cases, the patient tries to maintain the position in which he experiences the least pain (for example, pain syndrome in osteochondrosis of the lumbosacral spine);
• The forced position is provided by morphological changes in tissues or disturbances in the mutual arrangement of segments in the articular ends. These features are especially evident in dislocations.

Ankylosis and contractures, especially those that are insufficiently treated, are most often accompanied by forced settings that are typical for each individual joint. This group includes pathological settings that are a manifestation of compensation and in some cases are observed far from the affected area. For example, when a limb is shortened, a change in the pelvic axis is determined.

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The combination of external features of physique, height and constitution, posture and gait

An idea of the patient's appearance is obtained mainly from an examination based on a visual assessment of the following signs.

1. Features of body type - height, transverse dimensions, proportionality of individual regions of the body, degree of development of muscle and adipose tissue.
2. Physical condition, for the assessment of which the features of posture and gait are of considerable importance. Straight posture, fast and free gait indicate good physical training and health; pathological posture, slow, tired gait with some forward tilt of the body characterize physical weakness, developing with some diseases or with significant physical overexertion.
3. The patient's age, the ratio between his actual age and the estimated age based on the examination data. With some diseases, people look younger than their years (for example, with some early acquired heart defects), with others (for example, with atherosclerosis, lipid metabolism disorders, etc.) - older than their metric age.
4. Skin color, features of its color distribution, which are pathognomonic for certain disorders of general and local blood circulation, disorders of pigment metabolism, etc.

To objectify the morphological deviations noted above, anthropometric methods are used.

Types of Constitution

In our country, the most widely used nomenclature of constitution types is that proposed by M.V. Chernorutsky - asthenic, normosthenic, hypersthenic. Along with this, other names for these constitution types can be found in the literature.

The asthenic type of constitution is characterized by a narrow, flat chest with an acute epigastric angle, a long neck, thin and long limbs, narrow shoulders, an oblong face, weak muscle development, pale and thin skin.

Hypersthenic type of constitution - a broad, stocky figure, with a short neck, round head, wide chest and protruding belly.

Normosthenic type of constitution - well-developed bone and muscle tissue, proportional build, wide shoulder girdle, convex chest.

The given classification suffers from a significant drawback, since it does not include intermediate types of constitution. That is why objective measurement methods of research are increasingly being used.

Posture

In addition to the physique, a person's habitual posture, or what is commonly called posture, is of great importance in their appearance. A person's posture is not only aesthetically important, but also influences (positively or negatively) the position, development, condition, and function of various organs and systems of the body. Posture depends on the position of the head, neck, shoulders, shoulder blades, the shape of the spine, the size and shape of the abdomen, the tilt of the pelvis, the shape and position of the limbs, and even the placement of the feet.

Normal posture is characterized by a vertical direction of the torso and head, lower limbs extended at the hip joints and fully straightened at the knee joints, an “open” chest, shoulders slightly pulled back, shoulder blades tightly adjacent to the chest, and a tucked-in stomach.

In a person of correct physique, in a normal, relaxed stance with heels together and toes apart, the line of gravity as the vertical axis of the body begins from the middle of the crown, runs vertically down, intersecting the imaginary lines connecting the external auditory canals, the angles of the lower jaw and the hip joints, and ends on the dorsum of the feet. Normally, in a person with correct posture, the lumbar curve has the greatest depth in the region of the L3 vertebra _; in the region of the _Th12 vertebra, the lumbar curve turns into a thoracic curve, the apex of which is the Th6 _vertebra.

Signs of normal posture

1. The location of the spinous processes of the vertebral bodies along the plumb line, dropped from the occipital tubercle and passing along the intergluteal region.
2. The shoulder blades are positioned at the same level.
3. The corners of both shoulder blades are located at the same level.
4. Equal triangles formed by the body and freely hanging arms.
5. Correct bends of the spine in the sagittal plane.

Postural disorders most often manifest themselves as an increase or decrease in the natural curves of the spine, deviations in the position of the shoulder girdle, torso and head.

The development of pathological (non-physiological) posture is based on the following unfavorable factors:

• anatomical and constitutional type of spine structure;
• lack of systematic physical training;
• visual defects;
• nasopharyngeal and auditory disorders;
• frequent infectious diseases;
• poor nutrition;
• bed with a soft feather bed and spring;
• desks that are not appropriate for the student's age;
• insufficient time for health-improving physical exercise, insufficient time for rest;
• poorly developed muscular system, especially of the back and abdomen;
• hormonal disorders.

The most common posture disorders are the following: flat back, round and hunched back, saddle back, often accompanied by changes in the configuration of the anterior abdominal wall.

A combination of various deviations in posture is also possible, such as a round-concave, flat-concave back. Often there are violations of the shape of the chest, winged scapulae, as well as an asymmetrical position of the shoulder girdle.

Lateral curvature of the lumbar spine

Lateral curvature of the lumbar spine - ischalgic scoliosis, is quite common. The direction of scoliosis is indicated by the convex side of the lateral curvature. If this convexity is directed toward the affected leg (and the patient is tilted toward the "healthy" side), the scoliosis is called homolateral or homologous. If the direction is the opposite, the scoliosis is called heterolateral or heterologous.

Scoliosis in which the affected lumbar region also tilts the upper parts of the body is called angular. When the upper parts compensatorily deviate in the opposite direction, scoliosis is called S-shaped.

For ischalgic scoliosis, static-dynamic loads under the conditions of the affected disc are decisive. Against this background, in connection with the appearance of pain syndrome, special - analgesic and other mechanisms of spinal curvature are formed. Scoliosis is formed under the influence of a certain state of the spinal muscles, and they react reflexively to impulses not only from the root, but also from other tissues of the spine, innervated by the sinuvertebral nerve. If for a sharply expressed, especially alternating scoliosis, unilateral radicular impulses are probably decisive, then in other cases it is necessary to take into account the impulses from the posterior longitudinal ligament and other tissues both on the right and on the left. Many authors paid attention to the spinal muscles as a source of proprioception, an important role was given to the damage to the nerves of deep sensitivity and sympathetic nerves of the joints and muscles.

Scoliosis usually develops against the background of moderate and severe pain, and only severe fixed scoliosis is observed more often (more than twice) in patients with sharp and severe pain.

Angular scoliosis is especially common, less common is S-shaped, and a combination with deformations in the sagittal plane (usually kyphoscoliosis) occurs in 12.5% of cases. The formation of a second, oppositely directed peak in S-shaped scoliosis is obviously associated with the severity and duration of the primary curvature in the lower lumbar spine.

To assess the severity of ischalgic scoliosis, taking into account its dynamic nature, Ya.Yu.Popelyansky identified three degrees:

• 1st degree - scoliosis is detected only during functional tests (extension of the trunk, flexion and bending to the sides);
• 2nd degree - scoliosis is clearly visible during visual examination in a standing position. The deformation is not constant, disappears when sagging on parallel chairs and in a prone position;
• 3rd degree - persistent scoliosis that does not disappear when sagging on chairs and when the patient is lying on his stomach.

ATTENTION! Once scoliosis occurs, it remains for a long time, regardless of whether it appears for the first time or repeatedly in a given patient.

Alternating scoliosis is based on specific anatomical relationships between the disc herniation and the root. The herniated disc protrusions in these patients are never large and are usually spherical. This circumstance enables the patient, under appropriate conditions, to shift the root through the point of maximum disc protrusion to the right or left. Then one or another position of alternating scoliosis occurs. In such cases, bending the torso reduces the tension of the root over the disc herniation and facilitates changing the position of the torso. All patients with this form of scoliosis experience the phenomenon of scoliosis disappearance during traction (physical exercises, traction therapy). With this technique, radicular pain and scoliotic deformation disappear. These exercise therapy methods clearly confirm that the volume of the herniated protrusion, which decreases during traction, stops the tension of the root and irritation from it, and this immediately leads to the elimination of the deformation. However, as soon as the patient gets back on his feet, i.e. loads the spine and thereby restores the previous volume of the disc herniation, the previous radicular pain and scoliosis reappear.

A unified view of the occurrence of scoliosis in osteochondrosis explains not only the cause and their various types, but also facilitates diagnosis, allows for a more correct judgment about the course of the disease, as well as the effectiveness of treatment.