Comprehensive coverage of examination of spine.

1. Clinical evaluation of spine
Dr. Sairamakrishnan S

2. • Caring for patients with spine disorders can be extremely challenging
for clinicians because of the complexities of spinal anatomy and
pathophysiology and the multifactorial nature of pain.
• A thorough history and physical examination of a patient with a spine
disorder thus helps us to identify the nature of illness and the
prognosis of the same.

3. Differential Diagnosis
• Potential pain generators include muscles, tendons, ligaments, fascia,
anulus of the intervertebral discs, bone, zygapophyseal joints, dura
mater, nerve roots and dorsal root ganglia and vascular elements.

4. Medical History
“Red Flags”—What Not to Miss

5. “Red Flags”—What Not to Miss

6. “Red Flags”—What Not to Miss

7. “Red Flags”—What Not to Miss

8. Demographic data
• Name
• Age
• Gender
• Educational background
• Occupation
• Cultural milieu

9. Gender
• Males – Spondyloarthropathies; Infections; and Spine tumors
• Females – Osteoporosis; RA; Endocrine disorders; Polymyalgia

10. “Yellow Flags”—Predictors of Poor Outcome in the Patient’s History

11. “Yellow Flags”—Predictors of Poor Outcome in the Patient’s History

12. “Yellow Flags”—Predictors of Poor Outcome in the Patient’s History

13. Additional Assessment Tools
Questionaries
Pain drawings
Pain scales

14. Physical Examination
Observation
• Movement patterns
• Preferred postures
• Inconsistencies
• Gait abnormalities
Informal observation starts as soon as the patient enters the
consultation room.

15. Trunk and appendicular alignment
• The spine should be assessed for alterations from normal alignment
or resting curvature
• Particular attention to hip and knee alignment.

16. Gait
• High stepping gait – foot drop
• Wide-based gait – proprioceptive, cerebellar, or myelopathic
pathology
• Antalgic gait – musculoskeletal problem involving the hips, knees, or
foot and ankle (Generally, patients with a lumbar radiculopathy do
not exhibit an antalgic gait pattern)

17. Palpation
• Localized tenderness should be distinguished from diffuse tenderness
• In the cervical spine, palpation should include the occipital region; the
anterior neck; the clavicular, supraclavicular, and scapular regions
• In the thoracic region, palpation should also extend across the
posterior ribs.
• In the lumbar region, palpation should include not only the lumbar
spine but also the iliac crests, sacrum, sacroiliac joints, ischial
tuberosities, proximal hamstring, and greater trochanteric areas.
• Spondylolisthesis can frequently be appreciated by a palpable step-off
of the spinous processes

18. Neurologic Examination
• The key sensory points identified by
the American Spinal Injury Association
• Soft touch and pin-prick sensation can
be assessed well
• Should distinguish between a
dermatomal distribution suggesting
nerve root pathology from other
patterns
• Proprioception, vibration, position
sense, and temperature sensation can
be used to assess brain involvement.

19. Motor examination
• Strength
• Tone
• Coordination
• Muscle bulk
• Involuntary movements

20. Motor examination
• C5—shoulder abductors and external rotators
• C6—elbow flexors and wrist extensors
• C7—elbow extensors and wrist pronators
• C8—extension of index finger, finger flexion and abduction of thumb
• T1—finger abduction

21. • L2—hip flexion
• L3—hip adduction, knee extension
• L4—ankle dorsiflexion
• L5—great toe extension, ankle eversion, hip abduction and internal
rotation
• S1—ankle plantar flexion, toe flexion

22. • Strength is generally graded on a scale of 5 as follows:
5—active movement against full resistance (normal strength)
4—active movement against gravity and some resistance
3—active movement against gravity
2—active movement with gravity eliminated
1—trace movement or barely detectable contraction
0—no muscular contraction identified

23. • The presence or absence of focal muscle atrophy should be noted in
all patients.
• The mere presence of focal atrophy implies neurologic injury or
disease, and the distribution of atrophic muscles can be helpful in
defining the type of pathology present.
• Fasciculations associated with atrophic muscles imply the presence of
lower motor neuron injury.

24. • Muscle tone can be affected by many neurologic processes.
• Reduced tone suggests lower motor neuron involvement, whereas
increased tone or spasticity is seen with upper motor neuron disease.
• Coordination may be disrupted by numerous pathways, generally
involving the cerebellum or its pathways.
• Clinical methods to assess coordination include rapid alternating hand
and foot movements and finger to-nose testing.

25. • Reflex testing can further aid in the localization of neurologic injury
and help distinguish upper motor neuron from lower motor neuron
disease.
• In lower motor neuron injuries, deep tendon reflexes of affected
regions are generally reduced, whereas they are brisk in upper motor
neuron injuries.
• Babinski response (extensor) to appropriate plantar stimulation,
Hoffman sign in the hand, and clonus all can indicate the presence of
upper motor neuron injury.

26. • Biceps reflex—C5, C6
• Brachioradialis reflex—C5, C6
• Triceps reflex—C6, C7
• Patellar tendon reflex—L2, L3, L4
• Ankle jerk reflex (Achilles tendon)—S1

33. Special Tests and Provocative Maneuvers
Lhermitte sign,
• presence of an electric shock–type sensation radiating into the limbs
with cervical flexion.
• first described in a patient with multiple sclerosis
• If elicited with neck flexion, this sign should raise concern for the
presence of a cervical cord lesion.
• If elicited with trunk flexion, this may indicate a thoracic cord lesion.

34. Spurling maneuver – test for cervical nerve root compression.
• A positive test is elicited by extending, rotating, and laterally bending
the head to one side with reproduction of radicular pain into the
affected ipsilateral extremity.

35. Valsalva maneuver
• performed by having a patient hold his or her breath and bear down.
• A reproduction of the patient’s radicular symptoms or spinal pain
with this maneuver is believed to indicate a space-occupying lesion,
such as a disc herniation, in the spinal canal.

36. Hoffmans sign
• Flicking of the nail bed of middle finger produces flexion of index
finger and thumb

37. Inverted supinator reflex
• On performing brachioradialis reflex fingers go for flexion

38. Suprapatellar reflex
• Reproducing the results of patellar tendon reflex with striking of the
quadriceps tendon proximal to the patella

39. Dural tension signs
• Supine straight-leg raise test
• It is performed by elevating the leg with knee extended and assessing
for the reproduction of pain into the leg.
• The test is considered positive if pain occurs between 30 degrees and
70 degrees of elevation.
• Variations on this test include Lasègue sign or Bragard sign, which
involves raising the leg to the point of symptom reproduction and then
lowering the leg slightly and dorsiflexing the foot passively; a positive
test results in reproduction of the patient’s radiating leg pain.

40. • Crossed straight-leg raise
• Here symptoms are reproduced in the symptomatic leg by performing a
supine straight-leg raise on the contralateral leg
• Femoral nerve stretch test or reverse straight-leg raise
• This is done with the patient is prone and the knee is passively flexed,
with a positive test reproducing pain into the anterior thigh.
• A positive straight-leg raise test and its variations indicates tension on
the L4, L5, and S1 nerve roots.
• A positive femoral nerve stretch test indicates tension on L2, L3 and
L4 nerve roots.

41. Tests for assessing the sacroiliac joint
• Patrick test
• Gaenslen test

43. GAENSLEN TEST

44. UMN vs LMN
UMN LMN
Tone Hypertonia/Spastic Flaccid
Deep Tendon reflexes Exaggerated Absent
Babinski Positive Negative
Fasciculations Absent Present
Clonus Present Absent
Atrophy No disuse atrophy Present

45. Vertebral lesion Cord lesion
Pain Localised Neurogenic/radiating
Spine movements Painful Usually painless
Neurologic deficit May occur with late presentation Early

46. KEY POINTS
1. A thorough and appropriate history and physical examination are
essential in the assessment of patients with spine disorders.
2. It is crucial to identify “red flags” and “yellow flags” in a patient’s
clinical presentation.
3. The medical history can be used to narrow down the differential
diagnosis and direct further diagnostic efforts through physical
examination and other tools.
4. Physical examination findings become much more significant in the
context of correlating history and imaging.

47. 5. Psychosocial factors are a more important predictor of outcome in
patients with spinal pain than biomedical factors.
6. Pain is not a “thing” that can be excised. Pain is an experience, and
it is influenced by everything that is currently occurring in the life of
the patient. In addition to anatomic factors, it is important to look
for psychosocial factors that can affect a patient’s pain and distress.

48. Conclusions
• The history and physical examination of a spine patient is a complex
undertaking.
• Clinicians caring for patients with spine disorders need to be aware of
all of the issues that may affect the presentation of a patient and how
these issues can affect the delivery of care.
• It is of paramount importance to realize that the person presenting
with the spine problem is the primary concern, and the problem with
the spine is only secondary.
• Only by speaking with and directly examining a patient can clinicians
truly understand the nature of the problem that they are being asked
to address.

49. Thank You