Spine examination

Spine examination consists of a step-by-step evaluation of the pathology of the spine from inspection to special tests.

Spine Examination consists

History taking
General Examinations
Look
Feel
Movements and Measurements
Special tests
Neurological evaluation

History taking in Spine Cases

Mechanical Back Pain
Radicular Pain
Instability
Claudication
Inflammatory
Infective
Tumor

Mechanical Back Pain	Radicular Pain	Instability	Claudication	Tumor/Infection	Inflammatory Pain
Non-radiating	Pain along with particular dermatomes	Early morning pain	Absence of pain	Rest pain	Early morning stiffness
Axial	a/w numbness and paresthesia	Pain in the change of postures (catchy pain)	Heaviness, tingling, and paresthesia are complaints	Night Pain	Associated with polyarthralgia/ enthesopathy
Aggravated with activities	Radiated below knee	Referred pain, mainly in the back of the thigh/ gluteal region	No dermatomal distribution	Severe pain even with slight postural pain	Reduced with activities
Ups and Downs common	Nerve root tension signs present initially	Not crosses knee	Aggravated by walking and standing	Constitutional symptoms	Worsen during cold climate
No Red flag signs	H/O Slippage of slippers	Relieved by forwarding bending

Common differences between causes of Pain in the lower back

Red Flag Signs of low back pain

Fever
Loss of weight/appetite
History of cancer
Neurological deficit
Rest pain
Night pain
Extremes of ages

[Neurological Vs Vascular claudication] and [Intramedullary Vs Extramedullary compression]

General Examinations

Look for Gait: Gait Examination

Pallor/Icterus: Malignancy

Lymphadenopathy: Matted Lymph nodes, Tuberculosis

Cafe au lait spots

Chest Expansion is evaluated at the 4th Intercostal space for Ankylosing Spondylitis

Attitude

A statue-like stooping posture: Ankylosing Spondylitis

Crossed leg and tendency to the equinus: Cerebral diplegia (Cerebral Palsy)

Swaying of the body (Feet close together): Cerebellar lesion

Surface landmark of vertebrae

External occipital protuberance
C₁
C₃: Hyoid bone
C₄: Upper border of thyroid cartilage
C₆: Opposite to cricoid cartilage
C₇:: Vertebral prominence
T₂: level of the sternal notch
T₄: Against the angle of Louis
T₇: Inferior angle of scapulae
L4: Highest point of the iliac crest
S₁-S₂: PSIS

Inspection (LOOK)

From Sides

Look for Spinal curvatures from top to bottom

From Back

a. Position of head

Straight/ tilted (torticollis)- RUST SIGN: Supporting the head

b. Level of Hair Line

Normally parallel to the shoulder

c. Length of Neck

Normally equal

In torticollis, the length of the tilted head to shoulder is less

d. Level of shoulder

Normally parallel to the ground/ Hairline

e. Level of the scapula

In scoliosis, there is a decrease in the distance between the costal margin to the pelvis

f. Deformity

Kyphotic/ Scoliosis

Knuckle: single vertebrae, (eosinophilic granuloma, metastatic, Lymphoma, central TB)

Angular: 2-3 vertebrae,(TB, Metastasis)

Rounded: Several vertebrae ( Scheuermann’s Disease)

g. Margin of trunk

h. Spinous process

i. Iliac crest

The pelvis is parallel to the ground where you check the level of iliac crest

j. Dimple of venous

h. Skin changes over the spine

k. Wasting of paraspinal, glutei, hamstring, and calf muscle

LOOK FOR NEUROCUTANEOUS MARKERS

Tuft of hair
Dermoid cyst
Nevus
Dimple
Hypopigmented macule
Cafe-au lait spot

In Scoliosis

Adams forward bending test

Examine patient in sitting position

Ask the patient to bend forward

Curve disappears (look from front/ side both)

Scoliosis is mobile and postural in origin

In the Sciatic list, there is no rotation

If Curvature remains, Scoliosis is fixed (Structural scoliosis)

If a rib hump is present, it confirms the diagnosis

From front

Look for :

Suprascapular hollowing
Level of scapula
Shape of chest
Rib humps
Abdominal protrusion
Costo-pelvic impingement
Ilio-costal distance
- Tip of the last rib to the highest point of the iliac crest
Ilio-occipital distance
- Tip of external occipital protuberance to the highest point of the iliac crest

Palpation (FEEL)

General palpation of the whole back from above downward

External occipital protuberances to the tip of the coccyx

While the patient has his/her arm across the chest

Keeping back in the neutral position

Mark mid spinal line from nuchal furrow to inter-natal cleft (Prominent)

Mark is done with a Skin Pencil

Then palpate

Central furrow
Paraspinal bulge
Sides of chest
The loins
Iliac crest
Sacro-iliac region
Buttocks

Central furrow

Palpation done for spinous process and interspinous gap

In wasting of paraspinal muscle: The Spinous process is more prominent

In the normal presence of paraspinal muscle: The Spinous process is less prominent

Tenderness of Spine

Direct Pressure Method

The direct Pressure Method is positive if any pathology in spinous process/ advanced pathology in the vertebral body

It is done by 3 fingers with a long finger in the spinous process

Twist Tenderness

Twist Tenderness is positive in early pathology in the vertebral body

Twisting pressure by a thump on either side of the spinous process

Deep thrust method

When the above method has not indicated any tenderness/ disease may be chronic in nature or less aggressive in nature

Guarded thrust with the proximal part of the ulnar side of a fist over the spinous process

In Children,

ANVIL test

See in: Hip Examination

Is not advisable in pathology osteoporotic vertebral body as it indicates Caries spine

In Spinal Bifida Manifesta :

Look for the size, site, shape, content, and any impulse on coughing, and the transillumination test

Muscle Palpation:

The tone of paraspinal muscle spasm is tight (In spasm)

Deep pressure: Tender spasmodic muscle

Wasted muscle: Flattened bulge

Palpate posterior slope of the iliac crest- end up in dimple of venous/ superior to gluteal cleft/ superficial to two SI joint- location at PSIS

Pass fingers 5 cm vertically down: Edges of SI joint can be felt posteriorly.

Look for any tenderness in this zone

Sites for Paravertebral Abscess (Cold Abscess)

Cervical Region

Retropharyngeal (central in position) may bulge in the oropharynx
In mediastinum
At the back of the neck(one side of the midline)
- In the posterior triangle of the neck
- Infraclavicular region in axilla
- The lower part of the arm in the axillary, brachial artery, and posterior mediastinum

Thoracic region

Paravertebral abscess
Pyothorax
Post renal abscess
Lower and abdominal parietal abscess, rectal sheath abscess

Pelvis

Psoas/ Iliopsoas abscess
Even around lesser trochanter (Intraabdominal/ Intrapelvis)

Lumber

In front of groin and thigh
Back of thigh
Petits triangle(Intermuscular plane)

Movements (MOVE)

DO NOT DO THIS EXAMINATION IF THE PATIENT HAS/ SUSPECTED TO HAVE A NEUROLOGICAL DEFICIT

Cervical movement

Atlantooccipital joint (Condylar Joint): Nodding

Atlanto-axial Joint (Pivot joint): Side-to-side rotational movements

Active Movements

Sit behind the patient

Fix the shoulder in the horizontal plane

Ask the patient

To touch the front of the chest with the chin

Extend head as far as possible

Touch ear in shoulder strap

Look forward to the right shoulder and left

Normal movements:

Flexion: 80°

Extension: 50°

Rotation: 80°

Lateral Flexion: 45°

Passive Movements

Ask the patient to sit in an erect position in a chair

Shoulder blades are stabilized in a horizontal plane by the left hand

Hold chin in a neutral position, test for backward bending and rotational movements

Support chest from the front and press with opposite hand over occiput-bends cervical spine function

Occiput to Wall Test (Tragus to wall Test)

Assessment of loss of extension: Ankylosing Spondylitis

When a person stands erect against the wall, his heel and scapulae touch the wall, any distance from occiput to wall denotes a forward stoop.

Trunk Movements

Flexion

Ask the Patient to Stand erect with Feet approximately together

Bend forward keeping your knee straight and touch down with the tip of your middle finger or within 7 cm from it

Limitation: Patient flexes to within 10 cm from the floor

Extension

Erect postures with the feet approximated

Bend backward, go as much as possible

Normally, the finger should go up to the popliteal fossa

Side Bending

Erect with feet approximated and knee straight

Bends toward the lateral malleolus

While another arm is diagonally opposite or closest to the side of the body

Normally, an extended middle finger can reach up to the level of the knee

Rotation

Thoracic spine(mainly) involved in rotation

The patient should be sited

Ask to twist around to each side (Arm folded in the chest)

Rotation is measured between the plane of the shoulder and pelvis

Normal range of motions

Flexion: Thoracic (45°), Lumber (60°)

Lateral Flexion: 30°

Extension: Thoracic (25°), Lumbar (35°)

Rotation: Thoracic (40°), Lumbar (5°)

Schober Test

Involve the Upper lumbar spine only

See for limitation of forwarding flexion of the lumbar spine

Procedure:

The patient stands erect

Draw a line joining two PSIS

From midpoint to this line, point 10 cm straight up in midline

Ask the person to bend maximum forward with a straight knee.

In normal, measures distance will increase from 10 cm to 15 cm (5 cm increase)

Modified Schober test

Methods:

Positioning tape (measuring 10 cm is kept at the venous of the dimple)

Mark skin at the 0-15 cm

Ask the patient to flex

Anchor the top of the tape with a finger and ask the patient to flex forward

The normal increment is 6-7 cm

<5 cm indicates pathology

Includes lumbosacral region also for evaluation

Chest Expansion

To check for Ankylosing Spondylitis

Measurement is done

At the 4^th Intercostal space during chest expansion during inspiration

Normal: 5 cm

<4 cm = Ankylosing Spondylitis

Measurements

Chin-bow to vertical angle (CBVA)- 30° in Ankylosing Spondylitis

Linear Measurements:

Iliocostal distance

Distance between lower costal margin to the iliac crest

Iliooccipital distance

Distance between occipital protuberance to the iliac crest

Sciatic List

Axillary Presentation: The patient turns to the same side to relax the nerve root

Shoulder Presentation: The patient will turn to the opposite side to relax the nerve root

Special test

Stress test of Spine

Significant in Ankylosing Spondylitis

The patient fully bend the spine forward, side, and backward in sequence 15-20 times

Pain relief in Ankylosing Spondylitis

Pain increases in PIVD, tumor, infections, etc

Cervical root stretch test

Should rule out any instability in the cervical spine

Lateral Stretch test

Lateral stretching of the cervical spine in opposite direction leads to pain alone affected nerve root

Cervical compression test

The initial stage of irritation

Methods:

Sit erect on a stool

Stand behind the patient with both hands over the vault of head

Give sudden brisk in line with the spinal column

Rotate the cervical spine by 45 degrees and ask to look at the ceiling

In each rotation give brisk compression

Augmentation of typical symptoms in the area of root distribution

Cervical distraction test

Holding at the occiput and chin

Elevate in neural position

Relieves symptoms of nerve irritation

Hand on head Sign (HOH)

Significant in Cervicobrachial neuralgia

Pain/tingling sensation gets exaggerated when the patient stands or walks with an upper limb hanging by the side of the chest

Symptoms decrease, when he takes the affected side, by holding it with his other hand over the head – Symptoms decrease significantly

Head supporting Head Sign (HSH)- Rust sign

In tubercular spondylitis: Pain (+/-) but keeps neck shift and avoids any attempt to moving

Supports head with hand to avoid spontaneous movement

Test for Thoracic Inlet Syndrome

Thoracic outlet syndrome

Adson test

Method

Ask the patient to sit on the stool

Affected side arm abducted 30°, extended and externally rotated

Palpate radial pulse

The patient is asked to look towards the side to be tested – Inhale deeply

Diminution/ Loss of radial pulse with development of supraclavicular bruit: Compression of the subclavian artery

Patient exhale, look forward and lower arm to the side

Obliteration or reduction

If there is a duplication of patient symptoms is usually significant

The Roos test

Also called Elevated Arm Stress Test (EAST)

Methods

Ask the patient to keep in the Surrender position

Shoulder abducted 90° and externally rotated 90° and Elbow flexed

The hand should be repeatedly slowly opened and clenched for up to 3 minutes / 15 times

Neurological and Vascular symptoms

The disappearance of the radial pulse

Paresthesia, Pain, Cramps, Weakness

Wright Maneuver

Abduct shoulder to 90°

Externally rotate arm

Neurological and Vascular symptoms

Hyperabduction test

Ask the patient to,

Abduct and hyperextended both the arm (behind the body)

Feel for the dimension of the pulse

Lumbar Disk Prolapse

ALWAYS START BY SCREENING THE HIP

A full range of rotation in hip performed at 90-degree flexion with/out pain in extremities – sufficient to exclude hip pathology

All the examinations for lumbar disc prolapse should be done in sequence order

Straight leg raising test

Method:

Raise the leg from the couch

First normal than painful

Watching the patient face

STOP, when a patient complaint of leg pain ( Lateral protrusion), Back pain (Central disc prolapse)

The pain must be below the knee, roots of the sciatic nerve involved

<30°: Diagnosis of PIVD

30°-70°: Suggestive PIVD

>70°: equivocal

Well leg straight test (Crossed SLRT)

After performing SLRT, proceed to Cross SLRT (Pain occurs when raising the leg opposing to the affected side)

If positive it is highly suggestive of large prolapse to the midline

Sciatic Stretch Test (Bragard Test)

After SLRT

Once pain occurs, then lower the leg until the pain disappears

Then dorsiflex foot: Pain and paresthesia ( Increase tension over nerve root)

Signify positive Sciatic stretch test/ Bragard test

Bowstring test

On SLRT

Once the level of pain is reached

Flex the knee slightly, apply firm pressure with a thump in the popliteal fossa overstretched tibia nerve

Radiating pain + paresthesia suggest [ nerve root irritation]: Bowstring test is positive

Reverse SLRT

The patient is kept in the Prone position

The suspected site Knee is fully flexed over the thigh

Normal – Tightness is an anterior region of the thigh
PIVD – Pain over the back or sciatic nerve distribution

Others:

Lasegue test

Fajersztajn test

In doubt/ malingering

Flip test

Ask the patient to sit up under the pretext of examining the back from behind

A genuine patient will flex the knee or fall back on the couch or pain

Magnuson Pointing test

Ask the patient to point to the painful sites on two different occasions after the interval

Fails to identify the same point suggest malingering

Aird test

Ask the patient to sit with the leg over the edge of the examination couch

Try to lift the leg until the knee is fully extended

If the extension is achieved which is equivalent to SLRT: 90°

Femoral Nerve stretch test(Reverse Lasegue test)

For assessing L_2,3,4 nerve roots

Prone position with other leg kept extended at hip and knee

Hold leg with 1 hand above the ankle

Other forearm/hand should rest in buttock at hip level

The femoral nerve is stretched along with the extension of the hip

Pain in ipsilateral buttock/thigh on full knee flexion

Test for SI Joint

The figure of 4 tests

FABER maneuver (Patrick Test)

In sciatic root impingent /affection of sciatic nerve:

Patient complaints of pain pointing towards greater sciatic notch and alone sciatic course

Piriformis Syndrome: Entrapment of sciatic nerve in piriformis muscle as it passed through the sciatic notch

Pain in the SI joint signifies SI joint pathology

Ganslen Test

Flex opposite side, keep on side of the bed, and hyperextended the examine joint

Pain signifies a positive test

Pump Handle test

Flex hip and knee and take to shoulder

Pain at SI joint: SI joint pathology

Cord Compression test/ Cervical myelopathy

The main finding is lower motor signs at the level of compression predominate

[ In the level of arms]

In the legs, Lower motor signs are present

Hoffmann’s test

Rapidly extend the distal phalanx of the middle finger by flicking its anterior surface (pulp)

Resulting in flexion of the IP joint of the thumb and index finger signifies a positive result

Positive in corticothalamic dysfunction

Dynamic Hoffmanns test

Repeat Hoffmann’s test while the patient flexes and extends the neck which often facilitates the response

Lhermitte’s Test

Flexion and extension of the neck produce an electric shock-like sensation in the legs signifying a positive result

Inverted radial reflex

Finger flex when the radial reflex is elicited

Clonus

Myelopathy hand

Myelopathy hand is indicative of pyramidal tract damage

It consists of 2 elements:

Kinetics
- Inability to rapidly flex and extend fingers (20 cycles in 10 seconds)
Postural
- Deficient adduction and often extension of ulnar 1-3 fingers
- Mild cases: Finger extended, little finger lies in slightly abducted position- If it can adducted position and cannot be held long (Power of abduction- Normal) which is the distinguishing feature from Ulnar nerve palsy
- Severe cases: The little, ring and middle finger may abduct and the same finger may flex and lose the power of extension

Neurological Examination