Rajagopalan

Professor & HOD, Dept. of Orthopedics

Raja Rajeswari Medical College& Hospital,
Bangalore
 Clinical examination of spine

• History
• Inspection
• Palpation
• Movement and measurement
• Neurology of the limbs

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 History
• Injury : type, violence, mechanism
(direct, indirect, rotational) site.
• Pain: onset, nature, site, radiation,
• Deformity
• ADL
• Bladder / bowel function
• Treatment

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 Inspection
• Start with the patient standing, then lying
prone and finally lying supine.
• General observation
– Does the patient look well?
– Assess the patient's posture - any obvious
conditions?

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 Patient Standing
• Remember to inspect from all sides
(front, laterally and from behind):

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 Inspection
1. Attitude and deformity
2. Position of head, shoulder, scapula
3. Rib hump
4. swellings, sinus, skin
5. Gait

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• Skin
– Scars (surgical scars)
– Sinuses (deep infection)
– Unusual skin creases
– Pigmentation
• Cafe au lait spots (Neurofibromatosis)
• Hairy patch (spinal dysraphism)
• Mongolian Blue spot (no clinical significance
- more common in asians)

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Cafe au lait spots Neurofibromatosis

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Mongolian Blue spot (no clinical significance -
more common in asians)
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• Lumps: abscess, tumour (e.g. sacral lipoma),
prominent paravertebral muscle spasm

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• Spine
– Kyphosis (exaggerated or reduced)
– Lumbar lordosis (exaggerated or reduced)
– Scoliosis (asymmetry of shoulder height /
trunk balance / loin crease)
• Round backing / hunched shoulders:
Schuermanns disease/kyphosis
• Gibbus :
• Any chest deformity

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 Klippel-Feil syndrome
• Low hairline due to short neck:
• Klippel-Feil syndrome:
• fusion or absence of cervical vertebrae;
• may be associated with Sprengel shoulder (undescended
scapula)

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• The wall test will unmask even wall test
small fixed flexion deformities:
• Ask the patient to stand with
the back straight against a wall.
• Observe whether the following
are in contact with the wall:
• Occiput
• Shoulders
• Buttocks
• Heels

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Patient Walking
• Observe the
gait

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 Gait
 Have the patient walk normally then on
their toes (tests S1) then on their heels
(tests L4/5).
 Observe for abnormal gait patterns
including
Antalgic
Trendelenburg
Short leg
Foot drop
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• Feel (sit behind patient)
• Palpate iliac crests bilat, draw line joining them crosses
L4-5 disc space.
• Palpate post superior iliac spines, line joining them at lvl
of S2
• Palpate betweent the spinous processes, d lumbosacral
jnx n sacroiliac(SI) jnt, paravertebral muscle.
• Look for tenderness, deviatn from vertical alignment,
step-off deformity (spondylolithesis), protective muscle
spasm
• Gentle percussion – for deeper lesions

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 Palpation
• deformity of the spine - steps or a steady
contour?

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vertebral tenderness - localised or general ?
paraspinal spasm and muscle tenderness
sacro-iliac tenderness in sacroilitis
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• Elsewhere:
• feel for peripheral pulses
• palpate groin and abdomen for
abscesses
• Chest, abdominal, rectal examination

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 Move
• Adam’s Flexion test – attempt to touch toes.
Note any asymmetry of ribcage n lumbar
paravertebral area (rib hump and lumbar
pillow) in scoliosis, rhythm n any pain in
motion.

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• Schober’s method (measures spinal excursion).

• Extension – ask patient to arch back, support

pelvis with your hands. Pain in PID n
spondylolysis.

• Lateral flexion – slide hand down each side.

• Rotation – patient seated, twist ard on each side

with arms folded. (movement almost entirely
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 Movts and measurements
• Measurement of mobility of the spine
• Movements
• Chest expansion
• costovertebral movements are gauged by
asking the patient to breathe in and out: the
distance between maximal inspiration and
expiration is normally 5cm.

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Measurement of mobility of the spine
• Mark 2 points, one in T1 and another in L1.
ask the patient to the extent possible.
Normally there is an increase by 8 cm.

• 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.
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 Neurological examination
• the patient is then asked to lie supine and
the straight leg raise test is performed.
• carry out neurological testing of power;
• sensation -
• reflexes -
• do a rectal examination - check tone,
power, sensation

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 Straight Leg Raising Test (SLR)
• This is a test for lumbosacral nerve root
irritation for example, due to disc
prolapse.

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• With the patient laid on their back:
• raise one leg - knee absolutely straight - until
pain is experienced in the thigh, buttock and calf.
• record angle at which pain occurs - a normal
value would be 80-90 degrees - higher in people
with ligament laxity
• perform sciatic stretch test - dorsiflex foot at this
point of discomfort - test is positive if additional
pain results.

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•A typical positive SLR is one that reproduces
the patient's sciatica between 30 and 60
degrees.

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• When the limit of SLR is reached, dorsiflexion
of the ankle produces acute accentuation of
pain.

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• straight leg raising, by itself, can produce pain
from a variety of sources, including myogenic
pain,ischial burisitis, annular tear, and hamstring
tightness, as well as herniated disc
• Pain upon straight leg raising before the leg is
raised 30 degrees cannot be due to disc prolapse
as the nerve root is not stretched within this
range.
• Another explanation of nerve root irritation
must then be sought.

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 Bowstring Sign
• sciatic stretch test
• performed after a straight leg raising test by
lowering the affecting leg a few degrees below
the point
• popliteal compression:
• applying compression to the popliteal fossa
tensions the sciatic nerve and should provoke
symptoms with a lesser degree of a SLR
(removing hamstring irritation as a cause of
symptoms)

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 Crossed SLR
• Crossed SLR - Severe root irritation is indicated
when straight raising of the leg on the
unaffected side produces pain on the affected
side.
• SLR is sensitive, but unspecific, whereas
crossed SLR is very specific, but its sensitivity is
low (Hakelius & Hindmarsh 1972, Spangfort
1972).
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• Straight leg raising has a sensitivity of 91%
• its specificity is only 32%
• it is useful in “ruling out” disc herniation when it is
absent.
• If present, crossed straight leg raising is specific
(98%, but is not very sensitive (32%)
• Therefore, it is useful to confirm (“rule in”) disc
herniation, but its absence is not meaningful.

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 How to assess for malingering -
Reverse sciatic tension test

• performed by plantar flexing rather than

dorsiflexing the foot
• if this results in increased complaints of pain,
then pt is malingerer

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 Schober's test
• Schober's test assesses the amount of lumbar
flexion.
• In lumbar spine flexion, hip flexion can
compensate to a considerable extent for a loss
of spinal flexion.
• Schober’s test done to objectively measure the
degree of spinal flexion.

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• Firstly identify the
Dimples of Venus.
• 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.

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• a mark is made at the
level of the posterior
iliac spine on the
vertebral column, i.e.
approximately at the
level of L5.
• The examiner then
places one mark 5cm
below this mark and
another about 10cm
above this mark.

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• 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.

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• The distance should increase to more than
21cm in a normal patient.

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• A modified way to demonstrate lumbar spine
flexion is to place several fingers over the lower
lumbar spinous processes and ask the patient to
bend forward and touch there toes as best as
possible.
• In a normal spine your fingers should move part.

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• If the increase in distance between the two
fingers on the patients spine is less than 5cm
then this is indicative of a limitation of lumbar
flexion.

• This test allows serial measurements for patients

with progressive disease to be undertaken.

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 Femoral stretch
• Have the patient lie prone.
• Passively flex the knee as far as it goes. In a
positive test the patient should feel pain in the
ipsilateral anterior thigh (i.e. the distribution of
the femoral nerve)
• Also pain may be exacerbated on hip extension.

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 Neurological assessment
• Neurological assessment is an essential part of
the examination of the spine.
• The examination should involve a full
assessment of muscle wasting, fasiculation,
tone, power, coordination / proprioception,
sensation and reflexes.
• perianal reflexes and sphincter tone should be
tested.

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Cervical Spine Physical
Examination
 Surface Anatomy
• Inspect from posterior aspect
• Vertebra Prominens : at the cervicithoracic
junction.(spinous process of C7)
• Loss of cervical lordosis : nonspecific reaction to
cervical spine pain
• More dramatic reduction: in ankylosing spondylitis

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 Inspection of cervical spine
• General observation at rest.

• Look for posture, symmetry (e.g. shoulder

height, scapular prominence, waist, pelvis), skin

(colour, scars, lesions, creases), muscle wasting,

joint swelling.

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 Inspection of cervical spine
 Deformity of the cervical spine is
unusual.
 Characteristic features may be seen in:
 cervical spondylosis
 Klippel-Feil syndrome - congenital short
webbed neck with a low hair line

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 acute torticollis
 Instability of the cervical spine may
easily be missed in a supine patient.
 Check that the patient can easily support
their head.

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 Inspection
• Observe the muscles for spasm or
contracture.
• Contracture of the sternomastoid may be due
to spasm, trauma or congenital cause.
• The latter may result in a torticollis, in which
the patients holds the neck rotated to the
side opposite to the lesion.
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 Inspection
• enlarged thyroid gland or lymph nodes may
be visible.
• An abscess may point in part of the neck.
• Instability of the cervical spine may easily be
missed in a supine patient.
• Check that the patient can easily support
their head.

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 Palpation
 Reveal a subtle deformity
 Detect paraspinal muscle spasm
 Point tenderness
 Palpate the spinous process in midline : tenderness in
emergency situation indicates spine instability
 Evaluate alignment, acute lateral shift due to unilateral
facet joint dislocation or fracture , increase in space due
to posterior ligamentous disruption.
 Palpate posterior facet joint firmer 2cm lateral to
midline
 Localize trigger points in area superior to spine of
scapula and between thoracic spinous process and
medial border of scapula
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 Range Of Motion
 The thoracic spine should be supported.
 Having patient sitting on a straight –back chair extend to
midscapular level.
 Midrange pain due to instability of the structure being
moved.(degenerative disk disease)
 To assess flexion , attempt to touch chin to chest.
 To assess extension , tilt he head back , looking up the ceiling
 50% flexion-extension motion occurs between occiput and
C1
 Lateral rotation: rotate the chin laterally toward each
shoulder , in turn, typically 60 degree in each direction ,50%
normally occurs between C1 and C2.
 Lateral bending : attempt to touch each ear to ipsilateral
shoulder.
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 rotation
• Should be equal
• About 70-90% to each side.

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 Flexion and extension
• Full flexion when chin touches the chest
• Full extension of atleast 30* beyond the
horizontal should be possible.
• Usually greater in young people.

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 Lateral flexion
• Atleast 40* to each side.

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 • Cervical spine
flexion
“Touch your chin
on your chest”

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 Measurement
• ask the patient to flex and extend head
• a spatula held in the mouth acts as a
pointer to enable the range of movement
to be measured by goniometer: normal
range is 130 degrees.
• The occipito-atlantoid joint is primarily
involved.

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 • Cervical spine
extension
“Look up and
back”

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• Lateral
cervical spine
flexion
“Touch your
shoulder with
your ear”
(Both
sides)

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• Lateral cervical
rotation (Both
sides)
“Touch your
shoulder with
your chin”

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• lateral flexion: ask the patient to tilt his head
laterally from a neutral position; normal range is
45 degrees.
• Whole of cervical spine involved.
• rotation: ask the patient to look over his shoulder
• normal range is 80 degrees to either side.
• Rotation is a function of the atlanto-axial joint.

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 Muscle testing
• All strength tests should be done gently , providing
firm , control resistance.
• Lateral rotators: the sternocleidomastoid muscles
function as both rotator and flexor, innervated by
spinal accessory nerve ,isolated contraction rotates
cervical spine , fired together principal flexor of neck.
• Extensors: posterior intrinsic muscles and upper
portion of trapezius
• Lateral benders: powered by scalene

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Neurologic Examination

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Dermatomal distribution of the neck

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 Sensation.
• Know your C5 to T1 dermatomes.
• Test light touch and sharp/dull sensation.

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Sensory Evaluation by cervical
dermatoms

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NEUROLOGICAL EVALUATION

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Motor dermatomes Examination

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 SEGMENTAL NEUROLOGY
• When examining the cervical spine it is essential to
examine the segmental neurology.
• Root lesions may be indicated by weakness in the upper
limbs in a segmental distribution, with loss of
dermatomal sensation and altered reflexes.
• If cervical cord compression is suspected the lower
limbs should also be examined specifically looking for
upgoing planters and hyperreflexia.

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Reflexes

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 REFLEXES
• Muscle stretch reflexes. Test the following
reflexes:
• Biceps - C5/6
• Brachioradialis - C5/6
• Pronator - C 6/7
• Triceps - C7/8

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• Axial compression test :Determine if axial
compression test elicit patient’s symptoms.
• It should not be performed when a nerve root
compression with a motor neuron deficit is
suspected.
• Distraction test : may relieve symptoms.

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 Spurling ‘s test: in suspicious to lateralizing pathology such
as a disk prolapsed , the neck is extended and rotated
toward the involved side before the axial compression
applied.
 It exacerbates encroachment on the nerve root by
decreasing the dimensions of foramen.
 A patient may feel no discomfort , a sense of heaviness,
nonradicular or pseudoradicular pain or radicular pain.
 Muscle strains or mild ligamenous sprains are not
aggravated by test.
 Nonradicular or pseudoradicular pain radiates occiput,
shoulder, scapula and arm , but not below the elbow. In
spondylolisthesis and degenerative disk disease without
root compression.
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• Radicular pain radiates along the distribution of
specific dermatoma. In young individuals is the result
of nerve root compression due to intervertebral disk
prolapsed , in older due to foramen stenosis .
• Lhermitt’s maneuver: asking the seated patient
maximally flex the cervical and thoracic spine
• Lhermitt’s sign; the maneuver produces paresthesia
in extremity or trunk, indicative spinal stenosis and
resulting spinal cord compression.

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Thoracic & Lumbar Spine Physical
Examination

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1. Inspection
2. Gait
3. Movements
4. Sitting examination
5. Supine examination
6. Prone examination

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 Inspection of thoracic spine
• General observation of the standing patient.
• Look for posture, symmetry, leg length
discrepancy, skin (colour, scars, lesions, creases),
muscle wasting, joint swelling.
• Gait.
• Have the patient walk normally then on their toes
(tests S1) then on their toes (tests L4/5).
• Observe for abnormal gait patterns including
• Antalgic, Trendelenburg, Short leg, Foot drop

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 Deformities
• Deformities of the thoracic spine are
both common and important.
• Scoliosis:
• Kyphosis:
• Lordosis:
• this may be seen but is rarely a
serious problem

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Inspection of lumbar spine
 scoliosis is best seen with the patient
leaning forward.
 The normal lordosis of the lumbar spine
may be flattened by muscle spasm.
 Accentuation of the lordosis is rarely
serious.

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Thoracic spine
 Tenderness is elicited by light
percussion of the spinous processes
of the thoracic spine, with the patient
leaning forward.
 Rotational stress from the side.
 in cases of lumbosacral junctional
spondylolisthesis tenderness may be
accompanied by a palpable step.

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 Active range of motion.
• Ask the patient to perform the following
manoeuvers:
• Forward flexion - note the finger tip to floor
distance
• Extension - record as a % of normal

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 Lumbar flexion
“Try to touch your toes
without bending
knees”

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Lumbar extension Lateral lumbar flexion (Both
sides) “Slide your hand down
Lean back” your leg”
•Lateral flexion - note the finger
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tip to floor distance
 Thoracolumbar rotation
• Rotation - record
using degrees
• “Sit down and turn
round, looking over
your shoulder”
(Sitting down helps
fix the patients
pelvis)

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 Sitting examination.
• Perform the following examinations:
• Straight leg raising
• Muscle stretch reflexes
– Quadriceps - L4
– Gastroc/soleus - S1
• Muscle power
– Knee extension - L3/4
– Knee flexion - L4/5

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 Supine examination.
• Perform the following examinations:
• Straight leg raising
• reflexes
• Muscle power
• Examine hip joints
• Examine sacro-iliac joints

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 Clinical Evaluation
Lower Quarter Neurological Screen

Nerve Root Sensory Testing

Level
L1 Inguinal area (just below inguinal ligament
L2 Mid-thigh (medial)
L3 Medial knee (just above superior pole of patella)
L4 Medial aspect of lower leg, medial ankle, big toe
L5 Top of foot (an/or blow head of fibula)
S1 Lateral foot
S2 Posterior thigh, popliteal fossa
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• Sensation
• Know your L4 to S1
dermatomes
• Light touch, sharp/dull
sensation

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 Prone examination
• Perform the following examinations:
• Muscle power
– Hip extension with knee flexed - S1
• Prone extension test (femoral stretch test)
• Palpation

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 Clinical Evaluation
Lower Quarter Neurological Screen

Nerve Root Level Motor Testing

L1 Hip flexion
L2 Hip flexion
L3 Knee extension
L4 Dorsiflexion
L5 Great toe extension
S1 Plantarflexion
S2 NA
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 Clinical Evaluation
Lower Quarter Neurological Screen

Nerve Root Reflex Testing

Level

L4 Patellar Tendon
L5 Patellar Tendon
S1 Achilles Tendon
S2 Achilles Tendon

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 Clinical Evaluation
• Sacroiliac Dysfunction:
– History:
• Onset:
– Acute or insidious
• Pain characteristics:
– One or both SI joints; possibly
radiating pain in buttocks,
groin, thigh
• Mechanism:
– Prolonged stress
• Predisposing conditions:
– Postpartum women (relaxin
levels)
– Hormonal levels during
menstruation

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 Clinical Evaluation
• Sacroiliac Joint Dysfunction:
– Inspection:
• Levels of iliac crests, ASIS, PSIS
– Palpation:
• Pain over SI joints and PSIS
– Functional tests:
• Trunk flexion (with knees extended) will cause
movement of the sacrum on the ilia (pain)
– Neurological testing:
• Lower quarter screen
– Special tests:
• Long sit; SI compression and distraction; straight leg
raising; fabre; gaenslen’s; quadrant

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 Clinical Evaluation
• Sacroiliac Joint Stress Test:
– Test position:
• Subject supine; examiner stands
next to subject and with arms
crossed, places heel of both hands
on the subject’s ASISs
– Action:
• Examiner applies outward and
downward pressure with the
heels of both hands
– Positive finding:
• Unilateral pain at SI joint or in
gluteal/leg region is indicative of
anterior SI ligament sprain

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 Clinical Evaluation
• Sacroiliac Joint Stress Test:
– Test position:
• Subject side-lying; examiner
stands next to patient and places
both hands (one on top of the
other) directly over the subject’s
iliac crest
– Action:
• Apply downward pressure
– Positive finding:
• Increased pain indicative of SI
pathology (possible involvement
of posterior SI ligament)

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 Clinical Evaluation
• Sacroiliac Joint Stress Test:
– Test position:
• Subject lying supine; examiner
places both hands on lateral
aspect of subject’s iliac crests
– Action:
• Apply inward and downward
pressure
– Positive finding:
• Increased pain indicative of SI
pathology (possibly involving
posterior SI ligaments)

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 Clinical Evaluation
• Sacroiliac Joint Stress Test:
– Test position:
• Subject lying prone; examiner places both hands (one
on top of the other) over subject’s sacrum
– Action:
• Apply downward pressure on sacrum
– Positive finding:
• Increased pain indicative of SI pathology

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 Clinical Evaluation
• Patrick or FABER Test:
– Test position:
• Subject supine
– Action:
• Examiner passively flexes, abducts,
and externally rotates the involved
leg until the foot rests on the top
of the knee of uninvolved lower
extremity; examiner slowly
abducts the involved lower
extremity towards the table
– Positive test:
• Involved lower extremity does not
abduct below level of uninvolved
side
– SI pathology, iliopsoas tightness

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 Clinical Evaluation
• Gaenslen’s Test:
– Test position:
• Subject supine, lying close to edge
of table; examiner stands at side
– Action:
• Slide patient to edge of table;
patient pulls far knee up to the
chest; near leg allowed to hang
over edge of table
• Examiner applies downward
pressure on near leg, forcing it
into hyperextension
– Positive finding:
• Pain in SI region indicating SI joint
dysfunction

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 Clinical Evaluation
• Long-Sitting Test:
– Test position:
• Subject supine, both hips and knees extended;
examiner standing with thumbs on subject’s medial
malleoli
– Action:
• Examiner passively flexes both hips and knees and
then fully extends and compares position of medial
malleoli relative to eachother
• Subject slowly assumes the long-sitting position and
malleolar position is re-assessed
– Positive finding:
• Leg appears longer in supine but shorter in long-sitting
is indicative of an ipsilateral anteriorly rotated ilium
• Leg appears shorter in supine but longer in long-sitting
is indicative of an ipsilateral posteriorly rotated ilium

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 Some tips
• get the patient to stand on their toes, thus
checking plantar flexion of the foot and the S1
nerve root.
• If necessary, test each foot separately, giving
them some support with an outstretched arm.
• Ask them to rock onto their heels - test of
L4/L5

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