Clinical Examination of the Spine

Clinical Cases

  • Scoliosis
  • Spondylolisthesis
  • Spina Bifida
  • Foot Drop
  • Cervical Myelopathy
  • Ankylosing Spondylitis
  • Neurofibromatosis & Scoliosis
  • Spinal Stenosis
  • Cervical Radiculopathy
  • Lumbar Radiculopathy

Examination of the Spine

Look (Inspection)

  • Expose fully.
  • Assess from front and back for:
    • Pelvic or shoulder tip asymmetry.
    • Posterior rib cage prominence.
    • Sagittal alignment (normal curves).
  • Inspect skin:
    • Stigmata of neurological disease.
    • Scars.
    • Muscle wasting.
  • Observe specific areas:
    • Shoulder girdle (C5/C6).
    • Hand intrinsics (C8/T1).
    • Calf/Quads (L3/S1).
  • Gait Assessment:
    • General inspection for Trendelenberg or ataxia.
    • Heel-toe walking: Tests Tibialis Anterior (L4) and Gastrosoleus (S1).
    • Pigeon walking: Assesses balance and early signs of myelopathy.
    • Rhomberg’s Sign:
      • Eyes shut, standing still.
      • Excessive swaying indicates cerebellar lesion or myelopathy.

Feel (Palpation)

  • Palpate spinous processes from occiput down.
  • Check paraspinal musculature for spasm.
  • Assess SI joints, hips, and shoulders for associated pathologies.

Move

  • Assess range of motion (ROM) in cervical and thoracolumbar spine:
    • Observe for pain, restriction, or radicular symptoms.

Provocative Tests

Cervical Spine

  • Spurling’s Test:
    • Extend and rotate head to affected side.
    • Indicates nerve root entrapment.
  • Lhermitte’s Sign:
    • Flex and extend spine fully.
    • Electric-like axial pain suggests myelopathy.

Lumbar Spine

  • Straight Leg Raise (SLR):
    • Dorsiflex ankle to stretch sciatic nerve.
  • Cross-leg SLR:
    • More sensitive than SLR.
  • Bowstring Test:
    • Flex hip with semi-flexed knee, reduce hip flexion slightly, and straighten knee.
  • Femoral Stretch Test:
    • Extend hip and flex knee while prone.

Neurological Examination

Motor Power (MRC Grades)

  • Grades: 0: No power. 1: Flicker of movement. 2: Movement with gravity eliminated. 3: Overcomes gravity but no resistance. 4: Overcomes some resistance. 5: Normal power.

  • Myotomes:

    • C5: Deltoid, Biceps.
    • C6: Wrist extension.
    • C7: Wrist flexion.
    • C8: Finger flexion.
    • T1: Intrinsics, little finger abduction.
    • L2: Hip flexion, adduction.
    • L3: Knee extension.
    • L4: Ankle dorsiflexion, Gluteus medius.
    • L5: EHL, EDL.
    • S1: Ankle plantarflexion.

Sensory Assessment

  • Deep Pressure, Vibration, Proprioception: Dorsal columns.
  • Pinprick: Spinothalamic tracts.
  • Dermatomes:
    • C3: Supraclavicular fossa.
    • C4: Over ACJ.
    • C5-C8: Arm and hand distribution.
    • T1-T2: Medial arm/forearm.
    • L2-S1: Lower limb.
    • S2-S3: Posterior thigh, buttocks.

Reflexes

  • C5: Biceps.
  • C6: Brachioradialis.
  • C7: Triceps.
  • L4: Patella tendon.
  • S1: Ankle jerk.

Myelopathy Signs

  • Hoffman’s Sign:

    • Flick distal phalanx and observe reflexive thumb flexion.

  • Babinski Sign:

    • Stroke lateral plantar aspect of sole. Big toe extension indicates UMN lesion.

  • Clonus: 5 beats suggests myelopathy.

  • Jaw Jerk: Striking mandible causes rapid movement; lesion above spinal cord.

Nonorganic Signs of Waddell

  • Nonanatomic tenderness.
  • Simulation signs (e.g., axial loading, rotation pain).
  • Distraction test discrepancies.
  • Regional sensory or motor disturbance.
  • Overreaction during examination.
Back to top