EXAMINATION OF SPINE
CHIEF COMPLAINTS ;-

1. Deformities of back (Scoliosis/kyphosis/gibbus)

2. Pain in the back (kocks / IVDP)
3. Neurological weakness (kocks)
4. Swelling in the back.

H/O Presenting illness;-Eloborate on his chief complaints and don’t miss ADL and Negative
history,
ADL: - Is he able to do his daily activities like sitting, cycling, bending etc,
Negative H/o: -Weakness in upper limb(UL>LL weakness seen in central cord synd ),
sensory disturbances, fever, constitutional symptoms, weight loss, loss of appetite, H/o of
similar deformity, H/o breathing difficulty (Cos of compen. Scoliosis) H/o ligt. Laxity,
morning stiffness of back (AS), pain increase on coughing (IVDP), h/o incontinence bladder
and bowel (cauda equina syndrome )

Family history and menstrual history:- ( in cases of scoliosis)

GPE:- Look for neuro cutaneous markers, café au lait spots, lisch nodules, tuft of hair, chest
expansion, single breath count (30-40 per sec.)

GAIT:- Side lurching gait in scoliosis

LOCAL EXAMINATION :-

Gait;- stamping gait, etc.

Attitude ;-describe in standing and supine position start from cervical spine, level of
shoulder,

Deformity:- Scoliotic, kyphotic, (AS).

INSPECTION: - (from the Back)- look for

1. Position of head
2. Hairline, length of the neck (Klippelfiel syndrome )
3. Level of shoulders
4. Level of scapular
5. Prominences of iliac crest, swellings (cold abscess) scar, sinus, skin dimpling, tuft of
hair.
6. Look for scoliosis, lordosis, kyphosis
Eg. In Scoliosis:
a) Central furrow – deviation, convexity - ?
b) Site – eg. Thoracic lumbar or Thoraco lumbar
c) Side – right sided / left scoliosis
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d) Extent of curve – Upper & Lower end

e) No. of curves. – Adams tests – postural scoliosis disappears, make the patient sit
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compensatory curve disappears

 
 
f) Lateral margins – crowding of ribs, rib hump
g) Ilio costal distance -
h) Spina bifida manifestation – size, shape, content, impulse on coughing,
transillumination ( u will rarely get this case)
i) Step sign – lesthesis
j) Kyphosis – look for type single – knuckles, angular (>3 vertebrae), gibbus (2 -3
vert.)
k) Lordosis – look for exagg. Its due to FFD – Obliteration of lordosis – seen in
lesthesis, disc lesion.

From the Front :– Look for facial asymmetry, squint, sternum becomes
convex(pectus carinatum-pigeon chest , or pectus excavatum ) ,
Look for the level of nipple,
look for swellings (Cold Abscess) - ASIS, inguinal region, thighs.
From the Side :- Exaggerated lumbar lordosis, rib hump, chest wall abnormalities

PALPATION: - Check for –

1. Local rise in temperature

2. Tenderness – Superficial. –over the spinous process(point tenderness),
Deep – twist tenderness, and Deep thrust tenderness
3. Para spinal spasm
4. Confirm inspectory findings
5. Palpate and mark spinous process ascertain level ,look for step sign(lesthesis)
6. Plumbline – draw a line perpendicular from C7 – to natal cleft
7. Look for cold abscess – Ribs, thoracic, axial, petit triangle, inguinal region ,
thighs,popliteal fossa .
8. Chest expansion – to asses costovertebral movement – use ur hand

MOVEMENTS:-

Atlanto occipital – nodding occurs ,

Atlanto axial – rotation occurs

C spine:-
Flexion – Scl matoid – Sp. Part accessory nerve
Extension – trapezius, semisp. Capitis -
Side bending – scl. Mastoid – same

Cervical spine: Flexion – ask to touch chin to sternum, Extension ask to look at the roof, side
bending – ear should touch shoulder.

Thoracic :– little movement – look for Chest expansion

Lumbar :– Make patient sit on chairs

F – 0 – 900 Rectus abdominus Lower Intercostal Ask the patient to

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nerve . stoop forward

E – 0 - 300 Sacrospinilas , Q Adjacent. Spinal With hand on the
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lumb nerve D12, L1, L2 hips ask to bend

 
 
backwards
Transverse rotation – Extn. Oblique, Lower Intercostal Steady the pelvis
0 - 30 Internal Oblique nerve
Side bending – 0 -30 Q lumborum T12, L1, L2 Finger should go
below knees

MEASUREMENTS:-

1. External occipital protuberance – To angle of Acromion (Klippel fiel)

2. Iliac Crest – to Occiput
3. Occiput to Coccyx
4. Iliocostal distance – tip of the last rib to iliac crest
5. Chest expansion at or below the nipple (> 5 – 8 cms)(AS< 2.5)
6. Schobers test .

NEUROLOGICAL EXAMINATION:-

HMF:- Intelligence, speech, stereognosis, coordination, gen. appearance

Cranial nerves: - screen for nerve palsies , esp facial nerve palsy
Motor: -
Bulk – Hypertrophy, atrophy of the muscle
Tone – flabby or spastic muscle
Power – Muscle chart- hip, knee, ankle
Coordination – UL – finger to nose,
- LL- tibial shin, rhomberg sign

SENSORY ASSESMENT :-
Superficial- Touch, pain, Temp, two point discrimination
Deep-Deep touch, vibration, propioception, sterognosis,

Search for source

Vasomotor changes – starch iodine, guttman test

REFLEXES ;– superficial - Cremastric reflex, anal reflex

Deep – UPPER LIMB;- trepzius C3 – C4,
scapular – C5 – T1,
, Deltoid, C5 – C6,
Biceps C5 – C6,
triceps C6 – C7,
Supinator C5 – C6,

Abdominal . Upper – T7 – T10

Lower T11-T12
Cremastric – L1 ,
3

LOWER LIMB;-
Knee jerk L2- L3,
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Patellar Clonus,

 
 
Ankle Jerk S1 – S2,
ankle clonus, Plantar L5 – S1 ,
Anal S3 – S4,

Visceral:- Bladder & bowel – ask for retention dribbling, incontinence, burning ,Do a per
anal examination check for bulbocavernous reflex

VASCULAR:- Distal pulses –femoral ,popliteal , tibialis anterior and posterior,

Dorsalis pedis

Examination of Hip, knee, ankle, SI joints :-

Search for pressure sores. :-

Special tests ;-

1. SLR, active and passive (Lasegue’s)

2. Sciatic stretch test
3. FABER (Patrick)
4. Bowstring test
5. Femoral nerve stretch
6. Occiput to wall test – to screen Anky Spondylosis,
7. Schobers test (Modified) 10cm, PSIS – Increase length more than 10 cm.
8. Femoral nerve stretch
9. Lhermite sign

Localization of lesion;- In cases of paraplegia , or TB spine we have to find or localize the

site of lesion by physical examination only, then follow this method .
One is motor method means loss of motor power and find the level, and second is the sensory
method .

C5 – Flexion of elbow L2 – Flexion of Hip

C6 – extn. Of wrist L3 – Extn. Of knee
C7 – Extn. Of Elbow L4 – Control of DF ankle
C8 – finger flexion L5 – Extn. Of grade toe
T11- Abdn. Of fingers S1 – Planter flexion of ankle

You roughly asses the motor level and then Asses the level of lesion by sensory method –
more reliable (useful in cases of TBspine)

Pls note , the sensory level on examination roughly corresponds to the site of lesion , means if
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ur sensory level obtained is T10,at level of umbilicus in a paraplegic patient the site involved
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would be T10 vertebrae, but with some exceptions at cervical and thoracic and lumbar spine

 
 
therefore pls add to the level of obtained sensory level the following numbers as shown
below

For lesions from C1 – C7 – Add 1

T1 – T6 – Add 2
T7 – T9 – Add 3

T10 – L1 – L2
T11 – L 3 – L4 Add 4
T12 – L5 – S1

If there is sensory loss – highest level of sensory loss corresponds to level of cord damage

DIAGNOSIS;- ANATOMICAL- level of vertebrae involved, Disc level

PATHOLOGICAL – ivdp, discitis, spondylitis, paraplegia,quadriplegia,
infection.

INVESTIGATION;–

LABORATORY ;-
RADIOLOGICAL ;-X ray, TL spine, AP lateral, side bending films, pelvis xray
(Rissersign)
SPECIAL INVESTIGATIONS ;-
CT – 3 dimensional – size of pedicle, canal size
MRI – To know disc protrusion / cord abm. / Tethering / Diasto metarmelia

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SELF NOTES
 

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