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Spine Examination

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Special Test

Spine Examination

Content List

Spine Examination requires inspection, palpation, movements and special tests for the cervical, thoracic and lumbar region, although, in the clinical setting, a single region should rarely be examined in isolation.

Depending on the presentation and the location of symptoms, spine examination should be accompanied by examination of other areas; cranial nerves, chest, abdomen, rectal examination, peripheral neurovascular examination and screening of relevant joints, e.g. shoulder, hip, knee, foot and ankle. Gait should always be assessed as part of the examination, and may reveal a characteristic abnormality, e.g. a patient with cervical myelopathy typically has a broad-based, ataxic gait.

History Taking

Patients may present with a congenital deformity, degenerate condition or following trauma to the spine, and different conditions are obviously more prevalent in different age groups. If a patient presents with neck or back pain, enquire about the nature, exact location, timing of onset, and any radiation or referred pain. Other neurological symptoms include paraesthesia, loss of sensation, weakness, loss of coordination, gait disturbance and bladder or bowel dysfunction.

Ask how the symptoms impact on the patient’s daily activities, work and exercise, and establish if there is any potential for secondary gain, e.g. from ongoing legal proceedings. There are several validated disability scoring systems, e.g. Oswestry Disability Index. Enquire about any relevant past medical history or previous surgery, as many conditions can present with symptoms of spinal origin, e.g. rheumatoid arthritis, ankylosing spondylitis, tuberculosis, primary and secondary tumours, OA and degenerative neurological conditions.

Ask what treatment they have had in the past, e.g. medication, physiotherapy, acupuncture, etc. Patients with cervical spondylotic myelopathy can present with neck pain and stiffness with brachialgia, numb, clumsy hands or weakness, which is worse in the upper than in the lower limbs. The pattern of dysfunction is of a lower motor neurone deficit at the level of the compression with upper motor neurone signs below due to compression of the dorsal column of the spinal cord.

Cervical radiculopathy will present with pain, numbness and weakness in a specific dermatome or myotome in the upper limb. Thoracic cord compression is rare, as is thoracic nerve root impingement, which presents with rib or interscapular pain. Thoracic outlet syndrome (TOS) can present with symptoms of arterial, venous or nerve compression. Vascular TOS can present with a gradual worsening of upper limb pain and fatigue, particularly on overhead activity.

Neurogenic symptoms include painless atrophy of the intrinsic muscles of the hand, paraesthesia and reduced sensation in a C8/T1 dermatomal distribution, and less commonly pain. Mechanical low back pain is common, and may be postural or caused by discogenic pain of a degenerate lumbar spine. Nerve root impingement is commoner at the L4/5 and L5/S1 levels than in the upper lumbar region, and commonly presents with pain, paraesthesia, reduced sensation, and even weakness in a sciatic nerve distribution (L4/L5/S1), although patients can present with femoral nerve (L1/L2/L3) symptoms.

Bladder or bowel dysfunction and loss of perineal sensation are signals of cauda equina syndrome and warrant urgent further investigation and treatment. Patients with lumbar canal stenosis (spinal claudication) often present with pain radiating down both legs not associated with a single nerve root. The pain is exacerbated by walking or standing for prolonged periods and is relieved by sitting or leaning forwards. Patients with spondylolisthesis at L4/5 or L5/S1 often present with low back pain with or without sciatic symptoms.

Lower back pain is extremely common, but there are a number of features in the history which may indicate a sinister cause for the pain, including age under 20 or over 55 years, significant trauma, bilateral sciatica, systemic features of sepsis or neoplasia, and pain that is progressive, continuous and unrelated to activity. Any of these or a number of other ‘red flag’ symptoms warrants further investigation.

Cervical Spine Examination

LOOK

With the patient adequately exposed, look for any surgical scars, swellings, skin changes, asymmetry or differences between the upper limbs. Look at the posture of the neck. Is it held flexed? Is it hyperextended to compensate for a thoracic kyphosis? Does the patient have torticollis? In congenital torticollis, the sternomastoid muscle is larger on the side the head is tilted towards, whereas the opposite sternomastoid is larger in torticollis because of atlantoaxial subluxation.

FEEL

Standing behind the patient, palpate the spinous processes along the midline, working downwards from the occiput to include the prominent spinous process of C7 and the upper few thoracic vertebrae. Palpate the erector spinae muscles over the lateral aspects of the vertebrae, noting any tenderness and crepitus on flexion and extension. Palpate the anterior and posterior triangles of the neck, and for a cervical rib in the supraclavicular fossa. Finally, palpate the sternomastoid muscles, noting tension, swelling and asymmetry.

MOVE

Ask the patient to touch their chin onto their chest (forward flexion 75°), look up at the ceiling (extension 50°), touch their ear to their right and left shoulders in turn (lateral flexion 45°), and turn their head to the right and left (rotation 80°). Flexion and extension occurs mainly from C3–C7, with approximately 50° of rotation occurring at the atlanto-axial (C1/C2) joint.

Special tests

Thoracic Spine Physical Exam

LOOK

From the side, look for a kyphosis (increased thoracic spine convexity) or an acute angled gibbus, both of which may be congenital or acquired. Ankylosing spondylitis leads to a loss of the normal thoracic spine curvature and a reduced range of movement and lung expansion. From behind, look for swellings, café-au-lait spots, and any scars from previous spinal or lung surgery, in addition to scoliosis (abnormal lateral curvature of the spine).

Scoliosis which corrects on sitting, bending forwards in a seated position with or without lateral flexion is considered mobile (postural), and can develop secondary to leg length asymmetry. If these manoeuvres do not correct the deformity, or a rib hump becomes visible, the scoliosis is considered fixed (structural). A plumb line can be used for scoliosis examination, and the curves can be described as primary and secondary.

FEEL

Palpate the thoracic spine in a similar manner to the cervical spine, and gently percuss the vertebrae with the lateral border of a closed fist, noting any significant tenderness with the patient in a flexed forward position.

MOVE

The principal movement of the thoracic spine is rotation (40°); ask the patient to rotate from side to side with their arms folded across their chest while the examiner stabilizes the pelvis. Lateral flexion is approximately 15°, extension 5–10°, and flexion is limited by the orientation of the thoracic facet joints and the ribs. The thoracic and lumbar spines work as a unit, and movements are the result of these actions are achieved by movement in both sections of spine.

SPECIAL TESTS

Lumbar Spine Examination

LOOK

Look for scars of previous surgery and a hairy patch over the lumbar spine, indicative of spina bifida occulta. Look for scoliosis, which may be a secondary protective adaptation to sciatic nerve root impingement (sciatic list) or thoracic scoliosis. Measure leg length with the patient standing, noting any pelvic obliquity, and supine on the examination couch. Loss of the lumbar lordosis occurs commonly with OA and ankylosing spondylitis, and also with a prolapsed intervertebral disc. An exaggerated lumbar lordosis may be normal, especially in women, or found in conjunction with an abrupt step in spondylolisthesis.

FEEL

With the patient standing, palpate and percuss the lumbar spine along with the thoracic spine. The sacrum can also be palpated, along with the coccyx per rectum if indicated. The sacroiliac joints should be assessed with the patient on the couch. An abrupt step may be felt at the L4/L5 level, or at the lumbosacral junction due to spondylolisthesis.

MOVE

The lumbar spine has a good range of forward flexion (60°), extension (35°) and lateral flexion (30°). Only a few degrees of rotation is possible, and most rotation occurs in the thoracic spine. Ask the patient to bend forward and touch their toes, recording the distance from fingertip to floor, and perform a modified Schober’s test. Ask the patient to lean back as far as possible without losing balance, and slide their right hand down the side of their right leg and repeat on the left, comparing the two sides.

SPECIAL TESTS

Special tests used during physical exam low back pain

References & More

  • Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
  • Devereaux MW. Anatomy and examination of the spine. Neurol Clin. 2007 May;25(2):331-51. doi: 10.1016/j.ncl.2007.02.003. PMID: 17445732.
  • Piche J, Butt BB, Ahmady A, Patel R, Aleem I. Physical Examination of the Spine Using Telemedicine: A Systematic Review. Global Spine J. 2021 Sep;11(7):1142-1147. doi: 10.1177/2192568220960423. Epub 2020 Sep 22. PMID: 32959711; PMCID: PMC8351063.
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