Spine Physical Exam

CERVICAL SPINE
 LOOK
• Patient's posture,
movement, and behaviors
• With the patient seated,
note the resting posture
and alignment
• Inspect the skin anteriorly
and posteriorly
• Gait (broad base,
unsteadiness, abnormal
rhythm)
 FEEL
• Palpate the greater
occipital protuberance
(inion) while gently
supporting the head.
Note any tenderness.
• Next, palpate the
spinous processes C2 –
Th1, note any
tenderness
 Feel
Myofascial trigger point Fibromyalgia tender points

Suboccipital, mid to upper trapezius, supraspinatus and medial scapular borders

 MOVE
• Flexion
• Extension
• Rotation (R and L)
• Lateral flexion (lateral bending), R and L
Flexion Extension
Rotation Lateral Bending
 Move
• lf active ROM is limited
but does not reproduce
the patient's pain, adding
gentle, passive (examiner
initiated) force to assist in
attempted completion of
flexion, extension, or
rotation may reproduce
the patient’s symptoms
(suggesting the neck as
the site of origin of the
pain)
 Suspected nerve root irritation
• Neurologic Exam
– Motor and sensation C5-C8
• Spurling sign
• Abduction relief sign
 Neurologic exam
• C5:
– Reflex biceps
– Deltoid muscle strength
• Resisted shoulder
abduction
• Place the soulder at 45o
of abduction, ask him to
resist when applying
pressure at elbow
– Badge area sensation
 Neurologic exam
• C6:
– Brachioradialis reflex
– Biceps muscle strength
• Move patient elbow at
90o of flexion, place hand
under olecranon, ask
patient to flex the elbow
– Sensation at thumb and
index finger
 Neurologic exam
• C7:
– Triceps reflex
– Muscle triceps strength
• Patient elbow at 90o,
resist the elbow extension
– Middle finger sensation
 Neurologic exam
• C8:
– Interosseus muscle
strength
• Patient finger abduction,
resist by compressing
against finger abduction
– Little finger sensation
 Spurling Sign
• Reproduction of
radicular pain by
applying gentle/firm
pressure to occiput
during combined
rotation and extension
to the affected side
 Abduction Relief Test
• Ask the patient to place
the wrist or forearm of
the affected extremity on
the vertex of the skull
• Substantial improvement
or relief of upper
extremity pain with this
maneuver suggests nerve
root irritation as the
underlying problem
 Test for Myelopathy
• Hoffman Sign
• Hyper reflexia of the knee and ankle
• Ankle clonus
• Babinski sign
Hoffman sign
Babinski
LOWER BACK
 LOOK
• Patient standing
• Observe posture,
movement, and behaviors
• Observe gait
• Observe heel and toe
walking
• Observe resting posture,
alignment, and curvature
• lnspect skin
 FEEL
• Assess skin tenderness
to light touch
• Palpate spinosus
processes (mid T to
sacrum)
 MOVE
• LS flexion
• LS extension
• LS lateral bending
• Most importantly, note whether these
motions are painful and the location and
radiation of the pain
Flexion
Flexion
Extension
 Hips
• Patient Standing
• Trendelenburg test, R and L
• Patient lying
• Palpate trochanteric bursa (lateral trochanter)
• Palpate gluteus medius insertion
(superior/posterior trochanter)
• Hip flexion
• Hip external rotation
• Hip internal rotation
 Trendelenburg test
• Ask the patient to stand on
one foot. Note whether the
iliac crests remain level or
whether the pelvis drops on
the side opposite the
standing leg
• This pelvic "droop" is
referred to as the
Trendelenburg sign and is a
sensitive indicator of
intrinsic hip disease and/or
muscle weakness on the
weight-bearing side
Examination trochanteric bursa and
gluteus medius insertion
ROM exam
 Hip Pain
• Pain originating from
the hip joint itself is
usually felt in the groin
or medial thigh
 Hip pain
• Application of appropriate
pressure to assess the end
of internal rotation causes
the ipsilateral hernipelvis to
rotate upward in a cephalad
direction, jamming the facet
joints in the lower
lumbosacral spine on that
side
• Pain from the lower
lumbosacral facet joints is
usually felt posteriorly on
the same side at the level of
the belt line
 Nerve Root Irritation
• Patient lying
• Straight Leg Raising
• Straight leg raising (R and L legs; estimate
angle at pain onset)
• Patient sitting
• Reflexes
– Patellar reflexes (L4)
– Achilles re!lexes (Sl)
SLR and cross SLR test
 Nerve Root Irritation
• Muscle Strength*
• Foot inversion and ankle dorsiflexion (L4)
• Great toe dorsiflexion (L5)
• Foot eversion (Sl)
• "Quadriceps strength" (distracted SLR in sitting position)
• Sensation
• Medial foot and ankle (L4)
• Dorsum of foot (L5)
• Lateral fool and ankle (Sl)
• (Perianal sensation, anal rejlex, and sphincter tone [cauda
equina syndrome])
 Neurologic status
• L4:
– Check combined foot
inversion and ankle
dorsiflexion (L4)
– Asking the patient to twist
the forefoot toward the inner
aspect of the ankle and lift it
up toward the head
– Ask the patient to hold it in
that position while you apply
downward force on the
medial aspect of the forefoot
– The sensation of the medial
aspect foot and ankle
 Neurologic Status
• L5:
– Assess great toe
dorsiflexion
– asking the patient to
raise the big toe up
toward the head and
hold it in that position.
Apply downward force
with two fingers.
– Sensation at the dorsum
of foot
 Neurologic Status
• S1:
• combined foot eversion and
dorsiflexion
• asking the patient to twist the
forefoot toward the outer
aspect of the ankle and lift the
foot up toward the head.
• Weakness asses ankle
plantar flexor strength by
having the patient stand and
repetitively rise on the toes of
one foot while supporting
their arms against the wall.
• Sensation at the lateral foot
and ankle
 Suspected Psycological Distress:
Waddell categories
• Wadell Categories
– Superficial tenderness or nonanatomic tenderness
– Simulated rotation or axial loading
– Discrepant straight leg raises
– "Giving way" weakness or nondermatologic
sensory disturbances
– Overreaction
• 3 or more waddell categories Psychological
distress
 Sacroilitis / Spondyloarthropathy
• Age <40, inflamatory low back pain
• Patient standing
– Palpate/percuss Sl joints for tenderness (upper inner
buttocks)
– Modified Schober test of LS spinal mobility:
– 15 cm or more
• Patient lying
– FABER test (hip flexion, abduction, and external
rotation)
– Iliac compression (on superior anterior iliac spines)
 Modified Schober Test
• To asses lumbosacral
mobility
• Locate sacral dimple at
lumbosacral junction
draw a line between 10
cm above, 5 cm below
with spine in resting
neutral position
• Measure the distraction
with patient full flexion
• Normal > 5 cm
 FABER test
• Patient supine with hip
and knee Flexion,
abduction and external
rotation crossing the leg
• Apply pressure to
medial aspect of flexed
knee
• Produce sacroilliac pain
in same side of tested
limb
Illiac compression test
TERIMA KASIH