This PPT has very good description of examination of spine and it's patholgy

1. Presenter: Dr Arvind Kumar Anal
Moderator: Dr Ajoy Prasad Shetty

2. • Introduce yourself
• Ask for permission to perform examination
• Explain the patient first before proceeding
• The patient must be exposed adequately
• Do not perform any test causing pain to the patient
• Female patient, make sure the presence of female nurse or asssistant

3. • History
• General examination
• Inspection
• Palpation
• Movements & Measurements
• Neurology
• Special tests

4. History
1. Age
2. Sex (male / female)
3. Occupation
4. Socioeconomic class
5. Presenting chief complaints

5. 6. History of presenting illness
7. Treatment history
8. Past history
9. Personal history
10. Family history

6. Age:
Age Disorders
Child Spina bifida
Potts disease
Congenital scoliosis
Adolescent Idiopathic scoliosis
Mechanical back ache
Infections
Young adults PIVD
Ankylosing spondylitis
Tuberculosis
Middle age Spondylolysis
Spondylolisthesis
Tumors
Elderly Osteoporosis
Metastasis
Spondylosis

7. Sex:
Male Female
Ankylosing spodylitis
PIVD
Osteoarthritis
Osteomalacia
Ligamentous strain
Psychogenic backahe

8. Pain: (SOCRATES)
1. Site - cervical / dorsal / dorsolumbar / lumbar /
lumbosacral / sacral
2. Onset - sudden / insidious / gradual
3. Character - stabbing in PIVD
intermittent in spondylolisthesis
continuous or throbbing in osteomyelitis
dull aching in pott's disease

9. 4. Radiation
5. Associated symptoms - fever, nausea/vomitting
6. Time / Duration - diurnal variation, night pain
7. Exacerbating / Relieving factors - coughing,sneezing,rest
8. Severety - corelated with activity compromised

10. Other Symptoms like :
• Swelling - site, onset, when 1st noticed, duration, progression
• Deformity - onset, progression, association with pain
• Weakness - unilateral / bilateral
motor / sensory
sudden / insidious
bowel / bladder involvement
duration / progression

11. • Restriction of ROM
• Abnormality in walking
• Disability

12. Nurick Grading :
Grade Manifestations
0 Signs or symptoms of root involvement but without evidence of
spinal cord disease
1 Signs of spinal cord disease but no difficulty in walking
2 Slight difficulty in walking which did not prevent full time
employment
3 Difficulty in walking which prevented full-time employment or
the ability to do all housework, but which was not so severe as
to require someones' help to walk
4 Able to walk only with someone's help or with the aid of frame
5 Chair bound or bed ridden

13. Ask for:
• H/O trauma
• H/O constitutional symptoms
• H/O other joint involvement
• H/O pelvic infllamatory disease
• H/O significant unexplained weight loss (i.e, loss of >10% TBW in six
months)
• H/O steroid intake
• H/O malignancy

14. Past History
• Similar episodes of complaints
• Prolonged drug history
• Previous surgery
• Previous illness (DM / HTN / TB)
• Any neurological or hematological disorder

15. Personal History :
• Smoking / Alcohol
• Addiction of drug
• Diet & Appetite
• Bowel Bladder habit
• Sleep
• Mentrual history in females

16. Family History :
• Similar illness
• Tuberculosis

17. General Examination :
• Built
• Alert, Conscious, oriented to Time, Place & Person
• Pulse, BP, SPO2
• Respiratoy symptoms: wheeze/crepts/ rhochi
• Cardiovascular symptoms: murmur
• Per abdomen: tender/guarding
• Pallor, Icterus, Cyanosis, Clubbing, Oedema, Lymphadenopathy

18. Inspection:
Look for : Swelling / Sinus / Scar
Hair tufts / cafe-au-lait spots
Wasting
Standing Position :
1) From front: level of nipples
shape of chest
rib hump
abdomen protuberance

19. 2) From side: Cervical lordosis / thoracic kyphosis / lumbar lordosis
Manifestation Condition
Increased kyphosis Senile kyphosis (osteoporosis, osteomalacia,
pathological fracture)
Scheuermann's disease (osteochondritis of one or
more vertebra)
Ankylosing spondylitis
Gibbus (angular kyohosis) Fracture
TB spine
Congenital abnormality
Flattening or Reversal of lumbar lordosis PIVD
Oteoarthritis of spine
Infection of vertebral bodies
Ankylosing spondylitis
Increase in lumbar lordosis may be normal in pregnant females / obese
Spondylolisthesis
Secondary to increased thracic curvature
Flexion deformity of hips

20. 3) From back
• Position of head
• Level of posterior hairline
• Length of neck
• Level of shoulders
• Level of scapula
• Central furrow
• Lateral deviation from midline
• Iliac crest
• Dimple of venus
• Pelvic obliquity

21. Palpation:
• Temperature
• Tenderness:
a) Superficial - Malingers / Abscess
b) Deep - Posterior spine pathology
c) Rotatory - Facetal Pathology
• All spinous process : Prominence / Steps
• Paraspinal muscle spam
Kibler test- pinched skin over the paraspinal muscle will be less mobile when moved longitudinally

22. • Any swelling : Site
Size
Tenderness
Margin
Consistency
Fluctuation
*Spina bifida, Meningocoele in sacral region
*Congenital sacrococcygeal teratoma in sacrococcygeal region

23. Movements :
Cervical Spine Thoracolumbar spine
Forward flexion 75 to 90 degrees 90 degrees
Extension 45 degrees 30 degrees
Lateral flexion 45 to 60 degrees 30 to 45 degrees
Rotation (sitting poition) 75 degrees 45 degrees

24. Measurements :
1. Linear measurements:
a) From occipital protuberance to tip of coccyx
b) Iliocostal distance (tip of last rib to iliac crest)
c) Segmental measurement
d) Acromiooccipital distance

25. e) Schober's test
f) Ott test
2. Chest Expansion
3. Limb length dicrepancy

26. Schober's test:

27. Ott Test:
- Mark the C7 spinous process and
another point 12 inches distal to it.
-Request the patient tobend forward and note the
increase in distance between the above points.
-Normally it is 3cm or more.

28. Special tests:
• Stress Test of Spine:
Ask the patient to fully bend the spine forwards, sideways and
backwards in sequence for 15-20 times. Then ask him to move
about. He will feel relief in case of ankylosing spondylitis.

29. Cervical Roots Stretch Tests:
1. Lateral stretch test:
In cervical spondylosis or cervical disc prolapse, lateral stretch
of cervical spine in opposite direction may lead to pain along
the affected nerve root.

30. • 2. Cervical Compression Test:
Ask the patient to sit erect on stool, keeping the head in as
much neutral position as possible. Stand behind the patient
with both hands placed over the vault of head, give a
sudden brisk jerk in the line of spinal column.

31. Note the reaction of the patient specially regarding pain in cervical
region and referred area. Rotate the cervical spine to about 45 degree
to each side and ask him/her to look at ceiling. in each rotational
position, repeat the brisk compression manoeuvre and note the
patient’s reaction. In positive cases patient will complain of
augmentation of his typical symptoms in the area of root distribution
which used to be felt on and off.

32. 3. Distraction Test:
Passively distracting (stretch - elevating ) the head
in neutral position, by holding it at occiput and chin,
relieve the symptoms of of root irritation

34. 4. Hand On Head Sign:
Patients of cervicobrachial neuralgia (brachialgia) do complain of pain
with or without tingling in shoulder region , arm, forearm and even
upto fingers. The symptoms of pain and tingling exaggerate when the
patient stands or walks with that upper limb hanging by side of chest.
However, when he takes the affected side hand, by holding with other
hand, over the head, the symptoms decrease significantly.

35. 5. Hand Supporting Head Sign / Rust sign:
In tuberculus spondylitis of cervical spine, patient may or may not
complain of pain in neck and avoids any attempt of moving
(especially ) rotating the neck. While seating, he/she usually supports
the head wit hands (HSH sign).

36. 6. Lhermitte’s sign:

37. Test for Thoracic Inlet Syndromes:
Ask the patient to sit on the stool, stand on the side and behind the
patient on which side the test has to be performed.
Hold the wrist and palpate the radial pulse.
Ask the patient to flex the neck on affected side, while he elevates the
chin , press the lateral side of neck to the opposite shoulder as much
as possible.

38. At the same time, palpate the radial pulse of the extended limb.
Manifestations:
1) No change in pulse and no complaint - NORMAL
2)Radial pulse may get weaker or even get obliterated- Subclavian
Artery is getting stretched and compressed
3)patient may complain of reappearance or augmentation of tingling and/or
numbness in the affected area - BRACHIAL ROOTS are stretched or compressed

39. Thoracic Outlet Syndrome: ADSON’s Test
The patient is asked to sit on stool. The affected side arm is abducted ,
extended and externally rotated and the examiner simultaneously
palpates the radial pulse.
The patient is asked to look towards the side to be tested and inhale
deeply.
Diminution or loss of the radial pulse with development of a
supraclavicular bruit suggest significant compression of sub clavian
artery.

40. Tension Tests In Lumbar Disc Prolapse:
1. Straight leg raising test
2. Crossed leg raising test
3. Lasegue’s test
4. Fajersztajn test
5. Lateral flexion test of spine

41. 6. Sciatic stretch test
7. Figure of 4 test
8. Bowstring test
9. Sitting root test
10. Femoral nerve stretch test

42. 1. Straight leg raising test:
In Supine Position, the examiner will passively flex the patient’s hip
while maintaining the knee in full extension.
The examiner should make note of the degree of hip flexion where the
patient reported pain or reproduction of symptoms.
30 degree- diagnostic of PIVD
30 to 70 degree - suggestive of PIVD
>70 degree- equivocal

44. 2. Crossed leg raising test:
In supine position, the examiner will passively flex the patient’s
uninvolved hip while maintaining the knee in full extension.
A positive test is considered when the patient reports reproduction of
pain in the involved limb at 40 degrees of hip flexion or less in the
uninvolved limb.
The examiner should make note of the degree of hip flexion where the
patient reported pain or reproduction of symptoms.

46. 3. Lasegue’s test:
• While performing the straight leg raising test, the examiner lifts the
extended leg of a patient in a supine position.
• The test is said to be positive, when the patient experiences pain
along the distribution of the lumbar roots .
• The examiner stops the test when the pain is reproduced or
maximum flexion is got.
• The basis of this test is that the pain is reproduced due to stretching
of the lower lumbar and sacral roots when the leg is flexed.

47. 4. Fajersztajn test:
• In supine position, hip flexion on the unaffected side (to the end of
the available range or until the patient reports radicular symptoms on
the affected/contralateral side), having the knee at full extension
(with the examiner’s one hand holding the anterior aspect of the
patient’s distal thigh and the other hand holding the posterior aspect
of the patient’s ankle).
• Lower the leg slowly until the radicular symptoms are relieved and
hold the leg at this level,
• Sensitizing position: Ankle dorsiflexion. The return of radicular
symptoms on the contralateral leg, during ankle dorsiflexion on the
unaffected side with/without further straight leg raise (hip flexion)
indicates a positive test.

48. 5. FABER / Patric test

50. Neurological examination:
• Higher mental function
• Cranial nerve examination
• Gait
• Motor function
• Sensory function
• Vasomotor function
• Reflexes
• Visceral functions

51. Gait:
• Systematic, Coordinated, Rhythmic movement of body with a
tendency of forward propulsion of body center of mass with least
expenditure of energy.
• Abnormal gait patterns:
1. Antalgic gait - painful gait
2. Trendelenberg gait - hip abductor pathology
3. waddling gait- bilateral trendelen berg

52. 4. High stepping gait / foot drop gait / equinus gait
5. Stamping gait - sensory ataxia, leprosy
6. Alderman’s gait - gluteus maximus weakness
7. Festinant gait- Parkinsonism
8.Circumduction gait - fixed abduction deformity of hip

53. Motor system
1. Bulk of muscle (wasting or Hypertrophy)
confirm by circumferential measurement of the bulk, comparing
with normal side at a fixed point from knee and elbow joint line

54. 2. Tone of muscle :
• Hypotonia :
- Muscle become soft and pliable
- Provide little or no resistance to passive movements
- Due to LMN lesions
Cerebellar disease
Tabes dorsalis
Sensory neuropathies

55. • Hypertonia:
Spasticity-
- Increased sensitivity of the muscle to stretch resulting in
contraction by recruiting all the fibers within the muscle
- Velocity dependent resistance to movement associated
with exaggerated deep tendon reflexes
- occur due to Pyramidal tracts affection
- clasp knife type rigidty i.e, when the limb is rapidly flexe
d or extended, initially there is resistance, after which
there is sudden yield

56. • Rigidity:
- persistent elevated tone throughout a motion rather than
extraneous movement.
- Due to Basal Ganglion affection
- COG WHEEL TYPE: the resistance offered is jerky but periodic
and patterned throughout as movement in cogwheeel
- LEAD PIPE TYPE: uniform rigidity throughout the movement,
as in bending a lead pipe

57. • Hysteria:
- the resistance increases proportionately to the effort applied
by examiner
• Dystonia:
- oftten confused with spasticity.
- Dystonic postures are usually not correctable with
orthopaedic procedures
• Contracture:
- the mscle is wasted, fibrotic and shortened

58. 3. Power of muscle:
Medical Research Council (MRC) grading:
Grade
0 Complete paralysis
1 Flicker of contraction
2 Gravity eliminated movement possible
3 Possible against gravity , but not against examiner’s resistance
4 Possible against examiner’s resistance, but less in comparison
to normal side
5 Normal, full power

59. 4. Coordination:
For a definite motor action, certain separate muscle or group of muscles act in
synergism and cooperation to produce smooth, rhythmical, accurate activity in
proper harmony and correct sequence when coordination is intact
Ataxia: lossof coordination in maintaining proper posture
Apraxia: inability to translate an idea into a skilled act
Dysdiadochokinesia: inability to stop one motor action and substitute it
with its opposite action

60. Tests:
1. Upper limb: Finger to nose test
2. Lower limb: Heel-Shin-Ankle test
3. Romberg sign:
Ask the patient to stand with feet approximated and eyes closed.
If the test is positive, he starts swaying and even fail
4. Tandem walk

61. Upper limb nerve root supply:

62. Lower limb nerve root motor supply:

63. Lower limb dermatomes:

64. Reflexes:
1. Superficial :
a) Abdominal reflex (T7 to T12)
look at umbilicus while scratching the abdomen with
blunt end from periphery to centre
b) Cremastric reflex (L1,L2)
Absent in UMN & LMN lesions of L1,L2
c) Anal reflex (S3,S4)

66. d) Bulbocavernous reflex(S3,S4)
first reflex to return after spinal shock
e) Plantar response reflex (L5,S1)
In UMN lesion there is 1st toe dorsiflexion
Fanning of other toes
dorsiflexion of ankle &
Flexion of hip &knee

67. 2. Deep Reflex:
Grading
Grade interpretation
0 No response
1 or + Detectable only with reinforcement
2 or ++ Easible detectable
3 or +++ Brisk punctuated with occasional clonus
4 or ++++ Sustained clonus

68. Reflex Arc:

69. Reflexes and root value:
Deep Tendon Reflex Root value
Jaw jerk above 5th cranial nerve
Bicps jerk C5,6
Triceps jerk C6,7
Supinator jerk C5,6
Inversion of radial jerk C5,6 (UMN lesion)
Finger flexion reflex C7,T1
Knee jerk L2,3,4
ankle jerk S1,2
Patellar jerk L2,3,4 (UMN lesion)

73. Sensory Function Test:
A) Superficial :
1. Pain (tested with pin)
2. Fine touch (tested with wisp of cotton wool
or tip of index finger)
3. Temperature (tested with test tube containing
cold and warm water)

74. B) Deep:
1. Joint position sense
2. Vibration sense
- tested with a vibrating tuning fork of 128 Hz
placed over lateral malleolus, medial malleolus
and dorsum of first toe

75. C) Cortical:
1. Two point discrimination:
- tested with a pair of blunt divider
- for finger tips about 2mm separation
- for pulp of toes about 1cm of separation
2. Stereognosis:
- recognition of size, shape, weight and form
tested with common objects like paper weight,
pencils, keys etc

76. Vasomotor examination:
- Look for pallor, cynosis, redness, skin atrophy, nail bed
and subcutaneous tissues
- H/O Anhidrosis, Oligohydrosis & Hyperhydrosis
- Starch iodine test
- Guttmann’s test
sprinkle quinizarine powder on skin will turn into
purple color on contact with sweat

77. Visceral Assesment:
• Ask about bowel & bladder control
• Ask for scalding, difficulty in initiatin, frequency, precipitancy
• Ask for control of sphincters, feeling of passage of stool

78. Examination of other joints