EXAMINATION OF SPINE

Dr .RATISH KUMAR MISHRA

M.S ORTHOPAEDICS , FNB SPINE SUGERY
 General examination
HEAD TO TOE EXAMINATION
 GENERAL APPEARANCE
 WEIGHT
 HEIGHT
 BMI
 BUILT-WELL BUILT/THIN/ OBESE
 NUTRITIONAL STATUS
 VITALS – BP ,
PULSE,
RESPIRATORY RATE,
TEMPERATURE
 NOTE ANY ABNORMAL FACIES
 LIGAMENT LAXITY- BEIGHTON SCORE
 PALLOR, ICTERUS, CYNOSIS ,CLUBBING
,LYMPHADENOPATHY, EDEMA
INSPECTION FROM BACK
INSPECTION
POSITION OF HEAD-plumb line from
occiput inion-pass between clefts of
buttocks
LEVEL OF HAIR LINE
WEBBING OF NECK-Klippel feil
syndrome
SHORT NECK
LEVEL OF SHOULDER-scoliosis
Sprengel deformity
COMPARATIVE POSITION OF
SCAPULAR SPINE
LEVEL OF SCAPULAR ANGLE
LEVEL OF ILLIAC CREST- higher on
concave side in scoliosis
LATERAL BODY MARGIN- assymetrical
in scoliosis
LEVEL OF PSIS(DIMPLE OF VENUS)
SKIN FOR –
• HAIRY PATCH( spinal dysraphism)
• PORT WINE STAIN( spina bifida/
meningomyelocoel)
• CAFÉ AU LAIT SPOTS
( coast of california- smooth -NF1)
(coast of maine- rough -McCune
Albright Syndrome)
• NODULAR SKIN SWELLING- NF1
• SCAR ,
• SINUS,
• BED SORES- grade 1-4
DEFORMITY
SCOLIOSIS-
• SITE( thoracic/thoracolumbar /lumbar curve)
• SIDEDNESS(right/left convexity)
• POSTURAL/STRUCTURAL
• ADAMS FORWARD BENDING TEST
• FLEXIBILITY- FORWARD BENDING,
LATERAL BENDING
• COMPENSATORY CURVES
• RIB HUMP- on side of convexity in scoliosis
LIST- PIVD
Tilt same side -axillary disc
Tilt opposite side –shoulder presentation
 SWELLING or FULLNESS
paravetebral
petit triangle
Superior lumbar triangle
 PARAVERTEBRAL SPASM
 CENTRAL FURROW-normal/obliterated
 WASTING of paraspinal muscles,
glutei, hamstrings and calf muscles
INSPECTION FROM SIDE
Standing
(a) Look from the side
i.normal spine
>cervical lordosis( 20-40 )
>thoracic kyphosis(20-50;
avg 35)
>lumbar lordosis( 20-80
;avg 60)
• Deformity of the
cervical spine is
unusual.
• Note loss of lordosis
• Characteristic features may be
seen in:
• Sniffing position –ankylosing
spondylitis
 Increased kyphosis (posterior convexity of
the spine)
 senile kyphosis (with
osteoporosis, osteomalacia or
pathological fracture)
 Scheuermann’s disease
 ankylosing spondylitis
 Knuckle :due to 1 vertebra
 Gibbus :- 2-3 vertebra
 Rounded/angular kyphosis : involving more
than 4 vertebra
 fracture
 tuberculosis of the spine
 congenital abnormality
 . Lumbar curvature
> flattening or reversal of lumbar lordosis :
 prolapsed intervertebral disc
 Anterior wedging(
traumatic/osteoporotic)
 Long thoracolumbar spinal fusion
 infection
 ankylosing spondylitis
> increase in lumbar lordosis
 may be normal in females
 obese
 spondylolisthesis
 secondary to increased thoracic
curvature
 flexion deformity of the hips
*Note to be made of any flexion at hip
and knee
INSPECTION FROM FRONT
 HEAD POSITION---acute torticollis-wry neck
 STERNOCLEIDOMASTOID SPASM - TORTICOLLIS
 enlarged thyroid gland or lymph nodes
may be visible.
 An abscess may point in part of the
neck., axilla
 Chest shape : pectus excavatum,
pectus carinatum
 Level of nipples
 Umbilicus
 Abdominal protusion
 ASIS LEVEL
 Abnormal Swelling – neck , anterior and
lateral chest wall, iliac fossa
 Palpation
Mark
All spinous process
Spine of scapula
Angle of scapula
Iliac crest
PSIS
IMPORTANT SURFACE LANDMARKS
C7- Vertebrae prominens
T1- longest spinous process
T3-Spine of scapula
T7-Inferior angle of scapula
L4- Highest point of iliac crest
S2- PSIS
 PALPATION
LOCAL RISE IN TEMPERATURE
TENDERNESS
Palpate all spinous process( holdsworth test)-
to locate painful vertebra, abnormal
prominences, alignment of spine, iatrogenic
defect
 DIRECT TENDERNESS : pressure applied on
spinous process of vertebra-indicate
posterior or advance anterior pathology
 ROTATORY TENDERNESS- 2 methods to
elicit- give rotatory movement at base of
spine OR rotating diseased and adjoining
normal spinous processin opposite
direction.
 THURST TENDERNESS- thursting spine
with fist- indicate disease in anterior
vertebra
PALPATE STEP – spondylolisthesis or acute
fracture dislocation
DEFORMITY- confirm as seen in inspection
PARA SPINAL MUSCLE SPASM-
 elicited by tapping over paraspinal muscle
 direct pressure over spinous process
 kibler test- restricted movement of overlying
skin in case of spasm along the direction of
muscle
ANY SWELLING-
• site
• size
• shape
• margin
• consistency
• Fluctuation, cough
cold abscess
Spina bifida-meningocele in the sacral or occipital
region
Congenital sacrococcygeal teratoma in sacrococygeal
region
 In neck palpate posteriorly in the midline,
laterally, supraclavicularly - check for
cervical rib - and anteriorly.
 The front of the neck should be felt for
the thyroid, the anterior and posterior
cervical triangles for lymph nodes.
 Back of the neck for tender areas
and swellings.

 SI JOINT TENDERNESS
MOVEMENTS
 CERVICAL SPINE

 Forward flexion-CHIN TO
CHEST
Normal : 75 to 90 degrees
 Extension- LOOK at ROOF
Normal : 45 degrees
 Right/left lateral flexion(
touch your ear to shoulder)
Normal : 45 to 60 degree
 Rotation to
RIGHT/LEFT(touch your
chin to shoulder)
Normal : 75 degrees
 Thoracolumbar spine
 Forward flexion
(touch your toes without
bending knee-note position of
trunk in relation to vertical
plane)
Normal : 90 degrees
NOTE –finger tip to floor
distance(Normal < 7CM)
 Extension (lean back)
Normal : 30 degrees
 Lateral flexion to left and right
( slide your hand down your leg)
Normal : 30 to 45 degrees
NOTE: finger tip to floor
distance ( normal up to upper
1/3rd of leg)
 Rotation to left and right
( angle between plane of shoulder
to pelvis- sitting position helps in
fixing pelvis)
Normal : 45 degrees
 MEASUREMENTS
 Linear measurement
a.Iliocostal distance ( tip off last rib to
iliac cest)
b. Illiooccipital distance
c. Measure mobility of spine
d. Schober`s test

 Chest expansion
• At level of 4th intercostal space ,
• normal is around 5 cm
• < 2.5 CM is abnormal- ankylosing
spondylitis)
 Limb length discrepancy
 Measurement of mobility of the spine

• THORACIC SPINE: -Mark 2 points, one in T1 and

another in L1. ask the patient to bend to the extent
possible. Normally there is an increase by 8 cm.

• LUMBAR SPINE: -Mark 2 points, one in L1 and

another in S1. ask the patient to bend to the extent
possible. Normally there is an increase by 8 to 10 cm.
 MODIFIED SCHOBER’S
TEST
• Firstly identify the Dimples of
Venus(PSIS).
• Now in the midline, use a tape
measure and pen to mark a point
10cm superior to, and an other
mark 5 cm inferior to this point.
• Ask the patient to attempt to “touch
their toes”.
• The distance between these two
marks should be measured when
the patient’s spine is flexed
maximally.
• NORMAL >5 CM
• LIMITED FLEXION < 5 CM
 Special tests
 Cervical spine :
Spurlings test
Distraction test
Valsalva test
Swallowing test
Lhermitte’s sign
SPURLINGS MANEUVER
 Extension and rotate the head
toward affected side
 Press down upon the top of
patients head( axial loading)

 If there is increase pain in

either cervical spine or upper
extremity, note its exact
distribution. So, we can locate
the neurological level

 A narrowing of neural foramen,

pressure on the facet joints or
muscle spasm can cause
increase pain upon
compression
DISTRACTION TEST
 Place the open palm of one
hand under the pt’s chin, and
the other hand is upon occiput
 Then, gradually lift (distract)
the head to remove its weight
from the neck
 To demonstrate the effect that
neck traction might have help
in relieving the pain by
decreasing pressure on the
joint capsules around the facet
joints.
VALSALVA TEST

 Ask pt to hold his breath and bear down as if

he were moving his bowels

 Then, ask whether he feels any increase in

pain and describe the location

 This test increase intrathecal pressure

 If a space occupying lesion, such as a

herniated disc or a tumor present in cervical
canal, pt may develop pain in cervical spine
secondary to increase pressure

 The pain also may radiate to the dermatome

distribution of cervical spine pathology
SWALLOWING TEST

 Difficulty or pain upon swallowing

can sometimes caused by cervical
spine pathology such as :
Bony protuberance
Bony osteophytes
Soft tissue swelling due to
hematomas, infection or tumor
in ant portion of cervical spine
NAFFZIGER’S TEST

 manual compression of the

jugular veins bilaterally.
 An increase or aggravation of
pain or sensory disturbance
over the distribution of the
involved nerve root confirms
the presence of an extruded
intervertebral disk or other
mass.
LHERMITTE’S SIGN

 Passive flexion and

extension of neck cause
sharp electric shock like
sensation pain radiating
down the spine and to
both the extremities.
 This sign suggest cervical
cord compression or
irritation of the spinal
meninges by protrusion of
cervical intervertebral disc
or an extradural spinal
tumour.
 Special tests
 Thoracic and lumbar spine
Straight leg raising test(LASSEGUE’S SIGN)
BRAGARD’S TEST
Cross SLRT
Bowstring test
FLIP SIGN
Femoral stretch test
STRAIGHTLEGRAISINGTEST
STRAIGHT LEG RAISING TEST/LASEGUE TEST/
LAZAREVIC,S SIGN
 Supine on the examining table.
 First exclude that there is no
compensatory lordosis by keep
a hand beneath the lumbar
spine.
 The affected leg is then
passively and slowly raised by
the ankle with the knee fully
extended. Upon eliciting pain,
the exmainer stops further leg
elevation and records the range
of motion along with the area
of pain distribution.
PAIN AT <30 DEGREE- gluteal abscess or tumour, hip
pathology,malingering

PAIN BETWEEN 30-70 DEGREE- suggestive of lumbar

disc herniation

PAIN>70 DEGREE- hamstring tightness, pathology of

sacroiliac joint
Criteria for a true positive SLRT
 Radicular leg pain should occur (radiating below the
knee).
 Pain occurs when the leg is between 30 and 60 or 70
degrees from horizontal.
What findings should not qualify as a positive SLRT?
 Pain occurring in the low back alone.
 Pain occurring in the posterior thigh alone.
 Pain occurring at an angle less than 30 degrees - May
indicate non-organicity or hip joint pathology.
 Pain occurring at an angle more than 70 degrees from
the horizontal - More likely cause is tight hamstring or
gluteal muscles.
 Pain occurs in a normal person at an angle of 80 to 90
degrees
 Anatomy related to SLRT
 In normal conditions, there is a slack nerve root
pathway within the foramen. The normal average
excursion of lumbosacral nerve roots is about 4 to 6
mm, which decreases with age.
 This range of motion grants normal individuals a
greater degree of hip flexion (with an extended knee)
than patients with nerve root irritation, lumbar disc
prolapse for instance.
 In the case of disc prolapse, the already existed slack
nerve root pathway is taken up by the pathology.
 The loss of nerve root movement is mainly due to
adhesion secondary to the local inflammation and
could be due to mechanical compromise as well. Both
mechanisms work together to reduce SLR angle.
 BRAGARD’S SIGN

 At an angle when the patient had started feeling the pain

in SLRT,the ankle is pasively dorsiflexed.This causes
aggravation of the pain due to additional traction to the
sciatic nerve.
 Bowstring test
• After positive SLRT , the KNEE IS FLEXED
• Pain resolves with flexion at knee
• Pressure is applied with thumb in popliteal fossa to stretch
tibial nerve
• Occurance of pain paresthesia in leg indicate PIVD
Cross SLRT
 Also known as WELL LEG RAISING TEST OR CROSSED OVER
LASEGUE
 The patient lies supine on the examining table
 EXAMINER PERFORMS SLR ON PATIENTS
UNAFFECTED LIMB AND IT PRODUCES PAIN DOWN
THE AFFECTED LEG .
 Pathognomic of central disc prolapse
FLIP SIGN
ON LEG RAISING PATIENT LEAN BACK
FROM UPRIGHT POSITION AND
ASSUMES TRIPOD POSITION TO RELEIVE
PAIN
 FEMORAL NERVE STRETCH TEST

 A patient with lumbar disc prolapse may complain of pain

in front of the thigh,this indicates that probably the
protruding disc is l2-l3 which is irritating the femoral
nerve.
 The patient is asked to lie on his abdomen and flex the
knee of the affected side and hip is passively extended, if
this causes pain then its confirmatory that L2-L3 lumbar
disc is protruded to cause stretching of the femoral
nerve.
 SACRO –ILIAC JOINT

 Inspection –the patient is stripped and examined in

standing ,sitting and recumbent positions.
 The position of the sacro iliac joint is determined by
presence of dimple situated just medial to the posterior
superior iliac spine.
 In standing postion the patient is asked to point out the
site of pain and direction in which it radiate
 PALPATION

 Tenderness is elicited by placing the thumb over the

dimple and exerting pressure while the patient is asked to
bend forward.
 It may also be elicited by compressing the two iliac crests
together.
 Pelvic Compression
distraction test
• Examiner crosses arms and places them at the medialaspects
of the patientsASIS's
• A gapping pressure is applied in an outward direction
bilaterally and simultaneously
• The examiner then uncrosses his/her arms and places his/her
hands on the iliac crests toapply an inward/downward force
 FABER Test
• The patient's tested leg is placed in a "figure-4" position
• knee is flexed and the ankle is placed on the opposite knee
• The hip is placed in Flexion, ABduction, and External Rotation
• posteriorly-directed force against the medial knee ofthe bent leg
towards the
table top
• positive test occurs when groin pain or buttock pain isproduced
• sacroiliac joint dysfunction
SPECIAL TESTS

 GENSLEN’S TEST-
 The hip and knee joints of
the unaffected side are
flexed to fix the pelvis and
the hip joint of the
 affected side is
hyperextended over the
edge of the examining
table.
 This may exert a
rotational strain on the
sacro iliac joint and will
cause sharp pain.
 GILLIES TEST

• The patient lies prone on the bed. The pelvis of the

patient is kept steadied by clinician’s hand on the
normal sacro iliac joint. The thigh of the affected side is
hyperextended passively with the other hand of the
clinician. A sharp pain is felt by the patient when the
sacro iliac joint is diseased