AAOS Comprehensive Orthopaedic Review

Section 7 - Spine

Chapter 63. Physical Examination of the Spine

I. Introduction

A. General principles

 

1. The physical examination of the spine is a fundamental part of patient evaluation.

2. Specific neurologic changes should be sought.

 

3. A comprehensive examination also may identify nonspinal pathology.

 

4. Evidence of more extensive neurologic disease also may be found.

 

5. The physical examination should be tailored to complement patient history and radiographic findings.

 

6. The physical examination of the spine should follow the usual pattern of orthopaedic examinations.

 

a. Inspection of relevant body parts

 

b. Palpation of relevant structures

 

c. Tests for range of motion

 

d. Specific/more extensive neurologic examination

 

i. The neurologic examination should thoroughly quantify the extent of nerve compression along the entire axis of the spinal cord and spinal canal.

 

ii. A vascular examination also is important.

 

B. Provocative maneuvers

 

1. Examples: Lasegue sign, Spurling maneuver

 

2. High specificity for underlying compressive pathologies



II. Spine Examination

A. Inspection of the spinal column

 

1. Assessment of overall alignment

 

a. Typical sagittal alignment: lordosis in the cervical spine, kyphosis in the thoracic spine, lordosis in the lumbar spine, and kyphosis in the sacrococcygeal region

 

b. Patient should be viewed from both the front and back to look for any asymmetry in body structures.

 

c. Prominence of the scapula or rib cage may be indicative of an underlying scoliotic deformity.

 

d. Elevation of one side of the pelvis may be suggestive of degenerative scoliosis of the lumbar spine or a limb-length discrepancy.

 

e. Skin should be examined for cafe au lait spots (neurofibromatosis) and scars from previous operations (assess size, location, healing).

 

2. Assessment of the patient's ordinary gait

 

a. Trendelenburg or antalgic-type gait (might indicate painful arthritis of hip)

 

b. Wide-based, shuffling (neurologic disorder)

 

3. Inspection of the extremities should include search for focal muscle wasting.

 

a. Shoulder girdle wasting (C5 or C6 pathology)

 

b. Little finger abduction: myelopathy of the hand

 

c. Calf atrophy: chronic L5 and/or S1 weakness or neuropathy

 

B. Palpation

 

1. Palpation should begin with evaluation for point tenderness across the spinous processes, beginning at the occiput and moving the fingers down across the spinous processes of the cervical, thoracic, and lumbar spine.

 

2. Next, palpation should move laterally onto the paraspinal musculature at the costovertebral junction in the thoracic spine and across the facet joints in the lumbar spine.

 

3. The sacroiliac joints should be palpated for point tenderness in this region. Tenderness to palpation in the sciatic notch may be indicative of chronic nerve root irritation from herniated nucleus pulposus or spinal stenosis.

 

[

Figure 1. The Spurling maneuver.]

4. Percussive tenderness, when present, is often indicative of recent trauma and can help differentiate between an acute and chronic fracture.

 

5. Finally, gentle "hands on" manipulation may be attempted to determine whether any deformity identified on initial inspection can be passively corrected.

 

C. Range-of-motion testing

 

1. Motion varies by spinal region.

 

a. Cervical spine: flexion/extension, lateral bending, axial rotation

 

b. Thoracolumbar spine: flexion/extension and lateral bending

 

2. Describe any limitation or dysrhythmia.

 

3. Motion may be described relative to degrees of rotation or distance from a premarked object (eg, the distance from chin to chest on forward flexion).

 

4. Observe for and document any inappropriate behavior.

 

D. Provocative tests assist in differentiating between spinal pathology and underlying musculoskeletal disease.

 

1. Tests for cervical spine pathology

 

a. The Spurling maneuver (Figure 1) is very specific for nerve root compression in the lateral recess and/or foraminal zone.

 

i. This test is performed by applying an axial load to the neck while it is rotated toward the side of the pathology and placed into extension.

 

ii. The Spurling maneuver is positive when holding the patient in this position for 30 seconds recreates radicular symptoms, which may consist of pain, numbness, tingling, or paresthesias into the appropriate dermatome. These findings should occur ipsilateral to the lesion.

 

b. Lhermitte sign—Shocklike sensations radiate down the spinal axis into the arms and/or legs when the neck of a patient with cervical spinal cord compression is brought into extreme flexion or extension, causing stretch and direct compression of the spinal cord.

 

i. In patients with acute radiculopathy, this maneuver may reproduce the radiculopathy.

 

ii. Specific (not sensitive) for myelopathy

 

iii. Neither specific nor sensitive for identifying cervical radiculopathy

 

c. Impingement testing is used to rule out shoulder pathology.

 

d. The Phalen maneuver and Tinel sign are used to rule out carpal tunnel syndrome at the wrist.

 

2. Tests for lumbar spine pathology

 

a. Lasegue sign, or straight-leg raise test (

Figure 2)

 

i. Classically, this test is performed with the patient in the supine position.

 

ii. The reproduction of radiating leg pain (below knee) with hip flexion approaching 90° with the knee extended is highly sensitive for a herniated disk at L4-5 or L5-S1, causing ipsilateral nerve root compression.

 

b. Crossed straight-leg raise test

 

i. Passive flexion of the contralateral leg produces pain radiating down the symptomatic leg.

 

ii. If positive, this test is very specific and sensitive for a herniated disk.

 

c. Bowstring test

 

i. May be used in conjunction with the Lasegue test

 

ii. The leg is brought up toward 90° with maintenance of some knee flexion.

 

iii. As the patient begins to experience pain with passive flexion of the hip, the flexion is stopped and the knee is extended farther. In

 

[Figure 2. The straight-leg raise test.]

[

Figure 3. The Gaenslen maneuver.]

   a positive test, this will exacerbate the pain radiating down the leg.

 

d. Femoral stretch test

 

i. Nerve root tension sign for upper lumbar disk herniations

 

ii. Reproduction of symptoms with knee flexion and hip extension is highly sensitive for a herniated disk at L3-4, L2-3, or L1-2.

 

e. To rule out osteoarthritis of the hip, the hip should be brought passively through internal and external rotation to determine whether the patient has any significant restriction of motion that may be indicative of hip pathology.

 

f. To rule out sacroiliitis, use the Gaenslen maneuver (Figure 3) and the FABER (flexion-abduction-external rotation of the hip) test (

Figure 4).

 

3. Waddell signs—The presence of three or more of these five findings is highly suggestive of symptom magnification, nonorganic pain, and illness behavior.

 

a. Superficial tenderness

 

b. Simulation (producing back pain by pushing on the head)

 

c. Overreaction

 

d. Regional disturbances (entire leg numbness or weakness in a nonanatomic distribution)

 

e. Distraction



III. Neurologic Examination

A. Grading of manual muscle testing (

Table 1)

 

B. Gait testing

 

1. Tandem gait

 

a. The patient is asked to walk to the opposite corner of the room, turn around to face the examiner, and then walk toward the examiner, placing one foot in front of the other, touching heel to toe.

 

b. This test is sensitive for cervical myelopathy because subtle balance dysfunction can be an early finding in this disease. Other conditions may also cause difficulties with straight-line gait, however, including osteoarthritis of the hips and knees, upper motor neuron disorders, and vestibular dysfunction.

 

[Figure 4. The FABER test.]

2. Romberg test

 

a. Complement to straight-line gait test

 

b. Most commonly performed with the patient standing erect with the feet together and the arms in front and the eyes closed while the patient is observed for any swaying. Directionality and pattern of sway should be noted.

 

3. Heel walking and toe walking—The patient is observed while ambulating on the heels and then on the toes.

 

a. These tests will be abnormal if the patient has any significant weakness in the tibialis anterior muscle (difficulties with heel walking) or gastrocnemius-soleus complex (difficulties with toe walking).

 

b. The gastrocnemius-soleus complex is very strong. To assess full strength, the patient is asked to rise up and down on the forefoot 10 times while holding onto a table or wall for balance only.

 

i. If the patient is able to rise consistently onto the forefoot 10 times, the grade is 5 out of 5.

 

ii. If the patient is able to rise up only 4 to 9 times, the grade is 4 out of 5.

 

iii. If the patient cannot rise up 4 times, the grade is 3 or less out of 5.

 

C. Manual muscle testing

 

1. The neurologic examination should next move on to formal manual muscle testing of muscle groups

 

[Table 1. Grading of Manual Muscle Testing]

   C5 through T1 and L2 through S1. Standard muscle grading from 0 to 5 should be used, as described previously.

 

a. Cervical nerve root muscle testing is shown in

Figure 5.

 

b. Lumbar nerve root muscle testing is shown in

Figure 6.

 

2. A rectal examination is not routinely performed in the outpatient setting but should be performed in all patients who have sustained a traumatic injury and in patients manifesting any bowel or bladder dysfunction, as well as any patients with upper motor neuron disease. Key elements of the rectal examination:

 

a. Anal wink

 

b. Description of anal sphincter tone and perianal sensation

 

i. Bulbocavernosus reflex—Pulling on the Foley catheter or penis stimulates anal sphincter tightening.

 

ii. Recovery of the bulbocavernosus reflex implies the end of spinal shock.

 

D. Sensory examination

 

1. The sensory examination should assess pressure, which is mediated by the dorsal columns, as well as pin prick, which is mediated via the anterolateral spinothalamic tracts.

 

2. Sensory dermatomes are variable among patients, but there are relatively consistent areas (

Figure 7).

 

3. Thoracic levels generally reference the nipple line (T4 sensory level) and the umbilicus (T10 sensory level).

 

4. Evaluation of vibration and proprioception—Placing a tuning fork at the distal joints may help identify peripheral neuropathy, especially relative to diabetes mellitus.

 

E. Examination of reflexes

 

1. Upper extremity—Biceps (volar aspect of the elbow), brachioradialis (across the radial aspect of the proximal forearm), and triceps (just above the olecranon)

 

a. The biceps test, which represents C5, is best obtained by palpating directly onto the biceps tendon and striking this area with a reflex hammer.

 

b. The brachioradialis, which represents C6, may be tested anywhere across the forearm where it is prominent.

 

c. The triceps reflex, which tests the integrity of the C7 reflex arc, may require having the patient rest the forearm with the elbow in a flexed position and then applying enough tension to the triceps muscle to allow it to contract from the deformation of the reflex hammer.

 

2. Lower extremity—Limited to the patella and the Achilles tendon.

 

a. The patient should be relaxed, with the knee at the edge of a table and the lower leg hanging freely at an angle of approximately 90°.

 

b. In larger individuals, the quadriceps tendon is somewhat more lateral and must be struck in this position.

 

c. Achilles tendon testing is also best performed with the patient in a seated position.

 

d. The ankle may need to be flexed up to 90° to place enough tension on the Achilles tendon to allow deformation and a proper reflex jerk to occur.

 

3. Testing for long-tract findings

 

a. Very important in the diagnosis of cervical myelopathy

 

b. Key "pathologic" reflexes—Hoffman, Babinski, ankle clonus

 

c. Hoffman test

 

i. May be performed by flicking the distal phalanx of the long finger into an extended position while holding a more proximal portion of the finger. A positive test is indicated by an involuntary flexion of the thumb interphalangeal joint in the ipsilateral hand (

Figure 8).

 

ii. Alternatively, the Hoffman test may be performed by grasping the distal phalanx and "flicking" the distal phalanx into an extended position. Once again, involuntary flexion of the thumb interphalangeal joint is a positive finding.

 

iii. A positive Hoffman test is sensitive but not specific for cervical myelopathy.

 

d. Babinski sign

 

i. Accomplished by stroking the lateral portion of the plantar portion of the foot

 

ii. A positive Babinski sign is indicated by extension of the great toe with splaying of the smaller toes. This should be differentiated from withdrawal, when the foot itself withdraws from the stroke but the toes curl downward instead of up and out.

 

e. Ankle clonus may also be tested.

 

i. With the patient relaxed, the ankle is flexed rapidly.

 

[Figure 5. Neurologic evaluation of the upper extremity (C5, C6, C7, C8).]

   

 

[Figure 6. Neurologic evaluation of the lower extremity (L4, L5, S1).]

   

 

[Figure 7. Sensory dermatomes of the upper (A) and lower (B) extremities.]

[Figure 8. The Hoffman test.]

ii. Involuntary repeat contraction of the Achilles tendon and gastrocnemius-soleus complex for more than five beats and/or a positive Babinski sign is indicative of upper motor neuron disease, including cervical myelopathy.

 

4. Other neurologic tests

 

a. When myelopathy or upper motor neuron disease is suspected, testing cranial nerves 3, 4, 5, 6, 7, 9, and 12 may be helpful.

 

b. In addition, the jaw-jerk reflex may be tested by striking the middle of the mandible with a reflex hammer. Rapid opening and closing of the jaw in this reflex is indicative of upper motor neuron dysfunction that is centered above the spinal cord and may help determine that an underlying disorder is being caused by a problem other than spinal cord compression.



Top Testing Facts

1. A positive straight-leg raise test is highly sensitive for ipsilateral nerve root compression.

 

2. A positive crossed straight-leg raise test is highly specific for contralateral herniated nucleus pulposus.

 

3. Percussive tenderness on the spinous process is sensitive for acute/subacute vertebral fracture.

 

4. A positive Spurling test is highly specific for ipsilateral cervical root compression.

 

5. Three positive Waddell signs out of five correlates with nonorganic disease.

 

a. Superficial tenderness

 

b. Simulation

 

c. Overreaction

 

d. Regional disturbances

 

e. Distraction

 

6. An abnormal tandem gait test is sensitive (nonspecific) for myelopathy.

 

7. Reflexes can be tested for cervical roots C5, C6, and C7 and for lumbosacral roots L4 and S1.

 

8. Thoracic sensory levels are T4 (nipple line) and T10 (umbilicus).

 

9. Manual muscle strength grading: 3/5 strength is significant weakness but maintains antigravity.

 

10. Pathologic reflexes (positive Hoffman or Babinski, sustained clonus) are sensitive for myelopathy.



Bibliography

Albert TJ: Physical Examination of the Spine, London, England, Thieme, 2004.

Hoppenfeld S: Orthopaedic Neurology. Philadelphia, PA, Lippincott Williams & Wilkins, 1977.

Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976.

Malanga GA, Nadler SF (eds): Musculoskeletal Physical Examination: An Evidence-based Approach. Philadelphia, PA, Elsevier Mosby, 2006.

Maynard FM (ed): International Standards for Neurological and Functional Classification of Spinal Cord Injury. Atlanta, GA, American Spinal Injury Association, 1996.

Tong HC, Haig AJ, Yamakawa K: The Spurling Test and cervical radiculopathy. Spine 2002;27:156-159.

Waddell G, McCulloch JA, Kummel E, Venner RM: Nonorganic physical signs in low back pain. Spine 1980;5:117-125.