Examination of spine

Dr. Vaskar Humagain

Resident, NAMS
2076/06/28
 Introduction
• Caring for patients with spine disorders can be extremely
challenging for clinicians because of the complexities of
spinal anatomy and pathophysiology and the multifactorial
nature of pain.
• to identify relevant spine problems that have led to the issue
for which the patient is seeking care (e.g., the source of pain or
neurologic loss, anatomic derangements)
 History
• Pain:
– Onset
– Duration
– Site
– Nature
– Radiation
– Aggravating and relieving factors
– Postural variation
– Diurnal variation
 History

• Trauma
• Deformity
• Neurological symptoms
• Stiffness
• Constitutional symptoms

• Miscellaneous:
– Personal history
– Family history
– Past history
– Psycho-social background
Claudication
 Examination
• Look (inspection)

• Feel (palpation)

• Move

• Measure

• Special tests
 Cervical spine examination: Look
• Look (From front):

– General appearance
– Skin of neck
– Swelling
– Asymmetry in supraclavicular fossa (Pancoast
tumour)
– Wasting of muscles
– Torticollis
– Deformity
 Cervical spine examination: Look
• From side:
– cervical lordosis

• From back
– Skin condition
– hair line
– Deformity
 Cervical spine examination: Feel
• FEEL (Palpation)from behind the patient:

– Temperature
– Tenderness: (direct, twist, thrust)

– Any gap
– Deformity
 Cervical spine examination: Feel

• Palpate:
– Supraclavicular fossae
• Any mass
• Cervical rib
– Cervical lymph nodes
– Anterior neck including thyroid
 Cervical spine examination: Move
Lateral flexion: 45 degree Rotation: 80 degree
 Cervical spine examination: Move

• Patient sits erect on stool, from behind fix both shoulders in a

horizontal plane

• Flexion: 80 degree
 Cervical spine examination: Move

– Extension : 50 degrees
 Occiput to wall test / Flesche test

• Assessment of loss of extension

• normally, when a person stands erect
against the wall his heels and scapulae
touch the wall
• Any distance from occiput to wall:
forward stoop of neck
• E.g ankylosing spondylitis
 Cervical spine examination
• Crepitus:
– Spread hands on each of the
neck and ask patient to flex
and extend the spine
– Facet joint crepitus: cervical
spondylosis
 Special tests: Tests for Thoracic outlet
syndrome
• Look for evidence of ischaemia in
one hand ( coldness, discoloration,
trophic changes)
• Bilateral changes: Raynaud’s
disease
 Tests for Thoracic outlet syndrome
• Palpate radial pulse
• Apply traction to arm
• Obliteration of pulse is not diagnostic
but when the test reveals no change
when repeated on other side is
suggestive
 Test for Thoracic outlet syndrome
• ADSON’S test :
– abduct shoulder to about 30 deg
– locate radial pulse
– head turned to affected side
– take and hold deep breath then exhale
breath
– look forward and lower the arm to side:
reduction or obliteration of radial pulse
means positive test (compression of
subclavian artery)
 Tests for Thoracic outlet syndrome

• WRIGHT’s Test
– shoulder abducted, externally rotated,
elbows flexed 90(surrender position):
obliteration of radial pulse, paresthesia

• ROOS’s Test: hands repeatedly and

slowly clenched up to 3 min –pain
,obliteration of radial pulse
 Cervical Roots stretch test
Rule out any instability

• SPURLING’S TEST/ Cervical

compression test
– Rotate neck to one side with chin
elevated: if ipsilateral upper limb
pain and paresthesia reproduced:
suspicion of disc prolapse with
cervical root compression

ABDUCTION RELIEF SIGN/ hand on

head sign
• Pain may be relieved by having the
patient place the arm overhead
 Special tests for cervical myelopathy

• L’hermitte’s test
– flexion and extension of
neck:
– electric shock like sensation
particularly in leg
 Special tests for cervical myelopathy
• Hoffmann’s test:
– Rapidly extend the distal phalanx of
middle finger by flicking its anterior
surface:
– Positive: flexion of interphalangeal
joints of thumb and index:
corticothalamic dysfunction

• Dynamic Hoffmann test:

– Repeat while patient flexes and extends
the neck
 Special tests for cervical myelopathy
• Inverted radial reflex:
– Fingers flex when radial reflex is
elicited

• Clonus:
– rapidly flexing the foot into
dorsiflexion
– series of
involuntary, rhythmic, muscular
contractions and relaxations
 Special tests for cervical myelopathy
• Myelopathy hand:
– Kinetic: Normal is in excess of
20 cycles over 10 secs

– Postural: deficient adduction and

often extension of ulnar fingers
1-3.
 Thoracic and lumbar spine
• Look from front

• Look from side • Look from behind

 Look
• From front
– General appearance
– Gait
• Heel walking: ankle dorsiflexors (L4)
• Toe walking: ankle plantar flexors (S1)
– Position of the head
– Posture/list
– Level of shoulders
– Level of nipples
– Level of umbilicus
– Level of ASIS
– Attitude of hips
– Thigh muscles
– Level of patella
– Attitude of knees
– Foot position
 Look
• Look from side
– Normal thoracic kyphosis: 20-45 deg
• Kyphotic deformities: tb spine,
vertebral anomaly
– Knuckle, gibbus, round

– Normal lumbar lordosis: 40-60 deg

• Increased lordosis: females, obese,
spondylolisthesis, fixed flexion
deformity of hip, compensatory to
increased thoracic kyphosis
• Decreased lordosis: PIVD, infection,
ankylosing spondylitis, OA
 Look
• From back:
– head position
• Plumb line: from occiput to midline of sacrum
– Hair line
– Webbing of neck/short neck
– Position of shoulders
– Position of scapular spine
– Scapular angles
– Step off deformity
– List
– Kyphotic or lordotic deformities
– Iliac crest
– PSIS or dimple of Venus
– Lateral body margin
– Gluteal folds
– Popliteal fossa
– Calf muscles
– Ankle and foot position
 Look
• From back:
– Skin for
• Lumbar lipoma or hair patch
• Port wine stain (spina bifida/meningomyelocele)
• Café au lait spots
• Nodular skin swelling (neurofibromatosis)
• Dermal hemangioma
• Scars
• Sinuses
• Paravertebral spasm
• Swellings:
– Meningomyelocele
– Paravertebral abcess
– herna
 Look
• From back:
– Scoliosis
• Sidedness (left or right sided convexity)
• Adam’s forward bending test
• Lateral bending to look for possible correction and hence flexibility
• Compensatory curves

Postural scoliosis Short leg scoliosis Structural scoliosis:

prominent on flexion
 Feel
• Temperature
• Tenderness (direct, twist, thrust)
• Swelling
• Deformity
• Any gap, step off
 Feel
• Palpate on both sides of central furrow to note the tone of
paraspinal muscles
• Feel for renal angle tenderness

• Percussion tenderness:
– With rubber hammer, brisk tap over spinous process
– If above methods have not elicited tenderness
– Less acute pathology
 Move
• Flexion:
– Watch spine for smoothness of movement and any areas of
restriction
– thoracic: 45, lumbar 60

Note distance between Attempt to touch

fingers and ground Fingers reach
his toes
mid tibia
 Move
• Extension: thoracic: 25 degrees
– lumbar 35 degrees
– Pain: PIVD, spondylolysis

• Lateral flexion:
– 30 degrees on either side
– Pain: facet joint pathology
 Move
• Rotation:
– Pelvis should be fixed
– Better : done with patient seated, ask the
patient to twist round to each side
– Angle is measured between plane of
shoulders and pelvis

– Normal: 40 degrees
– Almost all by thoracic
– Lumbar : 5 degrees or less
 Measure
• Total length of spinal column: external
occipital protuberance to tip of coccyx
• Segmental measurements:
– C spine: occiput to vertebra prominence
(cervico dorsal junction)
– Lumbar spine: dorsolumbar spine to first
sacral spine
• Ilio-costal distance: tip of last rib to highest
point of iliac crest ( scoliosis, kyphosis)

• Ileo-occipital distance: occiput to iliac

crest, equal on both sides, disparity: side
bending of spine
 Measure
• Schober’s Test:
– Mark at 10 cm above line connecting
dimple of Venus
– Normal: should be at least 5 cm
– < 3 cm : suggestive of AS

• Modified Schober’s test:

– Mark at 5 cm below line connecting
dimple of Venus and another mark 15 cm
above
 Measure
• Chest expansion:
– Measure at the level 4th intercostal
space
– Normal: 6 cm
– < 2.5 cm: suggestive of ankylosing
spondylitis
 Special Tests
• Straight leg raising test (SLRT):
– < 30 degree: IV disc prolapse
– 30-70: S/O disc prolapse
– Pain must be below the knee if roots
of sciatic nerve are involved

• Well leg raising test or Crossed SLRT:

– pain and paresthesia on affected side:
large prolapse close to the mid line
 Special tests
• Fajersztajn Test:
– patient supine, raise leg from couch, stop
when pain, passively dorsiflex ankle:
accentuation of pain

• Bragaard’s test:
– if SLRT is +ve, leg lowered down by 10
degrees
– Foot dorsiflexed

• Lasegue’s test:
– Flex hip and knee
– Keeping hip flexed, extend knee
 Special tests
• Bowstring test:
– First do SLRT, once the level of
pain is reached, flex knee
slightly and apply firm pressure
with thumb over popliteal fossa
– Pain and paresthesia: nerve root
irritation
 Special tests
• Reverse lasegue test/ Femoral nerve
stretch test:
– Patient prone, flex knee
– Pain on anterior aspect of thigh
– S/O high lumbar disc lesions
– Pain aggravated by extension of hip
 Special tests
• Lateral flexion test of spine:
– Ask patient with suspected disc
prolapse to acutely flex spine
laterally on affected side
– If pressure over root from lateral
side: pain
– Flexing the spine on opposite side:
pain indicates pressure over root
from medial side
 Special tests
• Figure of 4 test (Patrick test or
Faber Manoeuvre):
– Flex, abduct and exterally rotate
lower limb of suspected side at the
hip an d flex knee so that foot rests
on the opposite lower thigh
– Jerky pressure over medial aspect
of knee
– Sciatic root impingement or
affections: pain pointing to greater
sciatic notch and along sciatic
course
 Special tests: Tests for malingerer

• Flip test:
– Ask the patient to sit up under the
pretext of examining back from
behind

– Genuine patient either flex knee,or

fall back on the couch with pain

– Malingerer-no difficulty
 Special tests: Tests for malingerer
• Aird’s Test:
– Ask the patient to sit with legs
over the edge of examination
table, try to lift the leg until full
extension of knee (SLRT = 90
degrees)
– There is no any sound organic
basis for any positive SLRT
 Tests for malingerer

• Apply pressure to the head

functional overlay is suggested
if this aggravates back pain

• Pinch skin at the back: such

superficial stimulation should not
produce deep seated back pain
 Neurological examination
Motor Sensory Reflexes

Motor examination:
Bulk, tone, power of key muscle groups

• Upper limbs: • Lower limbs:

– flexion of elbow: C5
– Extension of wrist: C6
– Extension of elbow: C7
– Flexion of distal
interphalangeal joints of
fingers: C8
– Abduction of fingers: T1
– Flexion of hip: L2
– Extension of knee: L3
– Dorsiflexion of ankle: L4
– Extension of big toe: L5
– S1: plantar flexion of ankle
Sensory Examination
 Reflexes
• Superficial Reflexes:
– Abdominal reflex (D8 -12)
– Anal reflex (S2-S4)
– Bulbocavernous reflex (S2-
S4)
– Cremasteric reflex (L1, L2)
– Plantar reflex (L5, S1)
• Deep Reflexes:
• Upper limbs:
– Biceps reflex (C5,6)
– Triceps reflex (C7)
– Supinator jerk (C5,6)
– Hoffman’s sign

• Lower limbs:
– Knee jerk (L2,3,4)
– Ankle jerk (L5, S1)
• Clonus
 Ankle clonus
 Patellar clonus
 Summary
• A thorough and appropriate history and
physical examination are essential in the
assessment of patients with spine disorders to
identify the physical manifestations of a spine
disorder and the root causes of the patient’s
distress, suffering, and disability.
 References
• Campbell’s Operative Orthopaedics, 12th edition.
• The Spine,Rothman-Simeone,6th Edition
• Apley’s system of Orthopaedics and Fractures 9th edition
• Clinical Orthopaedic Examination, McRae
• Clinical Orthopaedic Diagnosis, Pandey
THANK
YOU