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Examination of the Spine
Neck and back pain are common presentations in primary care. Many cases of neck and
back pain are due to benign functional or postural causes but a thorough history and
examination are essential to assess the cause, any associated psychological difficulties (eg,
depression, anxiety or somatisation disorder) and any functional impairment, including
restrictions with work, leisure and domestic activities.
General examination of the spine
The examination should begin as soon as you first see the patient and continues with
careful observation during the whole consultation.
It is essential to observe the patient's gait and posture. Inconsistency between
observed function and performance during specific tests may help to differentiate
between physical and functional causes for the patient's symptoms.
Inspection
Examination of any localised spinal disorder requires inspection of the entire spine. The
patient should therefore undress to their underwear.
Look for any obvious swellings or surgical scars.
Assess for deformity: scoliosis, kyphosis, loss of lumbar lordosis or hyperlordosis of the
lumbar spine. Look for shoulder asymmetry and pelvic tilt.
Observe the patient walking to assess for any abnormalities of gait.
Palpation
Palpate for tenderness over bone and soft tissues.
Perform an abdominal examination to identify any masses and consider a rectal
examination (cauda equina syndrome may present with low back pain, pain in the legs
and unilateral or bilateral lower limb motor and/or sensory abnormality, bowel and/or
bladder dysfunction with saddle and perineal anaesthesia, urinary dysfunction and
bowel disturbances, and loss of anal tone and sensation).
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Movement
The normal ranges of movement are outlined in the relevant sections below.
Examination of the spine must also include examination of the shoulders and
examination of the hips to exclude these joints as a cause of the symptoms.
Neurovascular examination
A thorough examination of sensation, tone, power and reflexes should be performed
Always consider the possibility of acute spinal cord compression, which is a
neurosurgical emergency.
All peripheral pulses should also be checked, as vascular claudication in the upper and
lower limbs can mimic symptoms of radiculopathy or canal.
Psychosocial factors
The assessment should include psychological, occupational and socio-economic
factors, which may either play a role in the cause of back problems, or be severely
adversely affected as a result of back problems.
Waddell's signs have been used to indicate non-organic or psychological component to
chronic low back pain:
Superficial non-anatomical tenderness.
Overreaction.
Pain on simulated maneuvers: pain on axial loading of skull, pain on passive
rotation of shoulders and pelvis.
Straight leg raise testing discrepancy: straight leg raising when sitting and when
supine not consistent; sitting test performed while distracting the patient.
Non-physiological examination: non-dermatomal sensory loss, cogwheel or give-
way weakness
Other tests have subsequently been developed.
A full psychiatric assessment may be required.
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Neck examination
Neck problems are common in general practice, either chronic discomfort, such as with
cervical spondylosis, or following acute trauma - eg, whiplash injuries following road traffic
accidents. Evaluation of any neurological symptoms in the upper limbs must include an
assessment of possible causes in the neck. Spinal cord compression in the neck may lead to
lower limb problems and abnormal gait, as well as bladder and bowel disturbance.
Neck inspection
Deformity: may be seen in cervical spondylosis or acute torticollis.
Instability of the cervical spine: check that the patient can easily support their head
(obvious if mobile but instability may be missed in a supine patient).
Abnormal head posture may be due to neck problems but also other causes - eg,
weakness of the ocular muscles.
Asymmetry (eg, of scapulae) or supraclavicular fossae (eg, Pancoast's syndrome due
to a malignant tumour at the apex of the lung).
Torticollis (the affected side and chin are often tilted to the opposite side) or
sternomastoid 'tumour' in infants. Causes of acquired torticollis include upper
respiratory tract infection, and vertebral malalignment or trauma.
Arms and hands: for wasting, fasciculation, motor abnormalities (tone, power), sensory
deficits and any indication of thoracic outlet syndrome.
Lower limb motor or sensory deficits may be caused by cervical spinal cord
compression.
Neck palpation
Palpate for tenderness and masses:
Posterior in the midline.
Lateral.
Supraclavicular - cervical, lymph glands, tumours.
Anterior - including thyroid examination.
Midline tenderness in the cervical spine: may be due to supraspinous damage following
whiplash injuries or may also indicate more major neck trauma.
Midline tenderness localised to one space is common in cervical spondylosis.
Palpate lateral aspects of vertebrae for masses and tenderness (the most prominent
spinous process is T1).
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Paraspinal tenderness radiating into the trapezius is common in cervical spondylosis.
Crepitation: facet joint crepitus may be detectable with flexion and extension of the neck
by either palpation or auscultation on either side of cervical spine; facet joint crepitus is
common in cervical spondylosis.
Cervical movement
Flexion: normal range is 80° with chin able to touch region of sternoclavicular joint.
Extension: normal range 50°, so normal for full flexion to full extension is 130°; primarily
involves the atlanto-axial and atlanto-occipital joints.
Lateral flexion: normal range is 45° to both sides; restriction of lateral flexion is common
in cervical spondylosis. Inability of lateral flexion without forward flexion at the same
time suggests atlanto-axial and atlanto-occipital joint abnormalities.
Lateral rotation: normal range is 80° to both sides; normally just short of plane of
shoulders at full rotation. Rotation is restricted and painful in cervical spondylosis.
Neurological involvement
Neurological features associated with cervical radiculopathy:
C5 nerve root:
Muscle weakness: shoulder abduction and flexion/elbow flexion.
Reflex changes: biceps.
Sensory changes: lateral arm.
C6 nerve root:
Muscle weakness: elbow flexion/wrist extension.
Reflex changes: biceps/supinator.
Sensory changes: lateral forearm, thumb, index finger.
C7 nerve root:
Muscle weakness: elbow extension, wrist flexion, finger extension.
Reflex changes: triceps.
Sensory changes: middle finger.
C8 nerve root:
Muscle weakness: finger flexion.
Reflex changes: none.
Sensory changes: medial side lower forearm, ring and little finger.
T1 nerve root:
Muscle weakness: finger abduction and adduction.
Reflex changes: none.
Sensory changes: medial side upper arm/lower arm.
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Thoraco-lumbar spine examination
Low back pain is a very common presentation in general practice. Although the cause and
severity of back problems are often fairly clear, it is often essential to make a thorough
assessment and detailed examination of the back. A thorough examination of the lower limbs
is essential.
Inspection
Observe for abnormal gait and posture, which may provide clues as to the nature and
severity of the problem.
Superficial landmarks include:
T1 is the most prominent spinous process at the base of the neck.
T7/T8: lower border of scapulae.
L4: iliac crests.
S2: dimples at posterior superior iliac spines.
Assess curvature: kyphosis, scoliosis.
Ask the patient to bend forwards: postural scoliosis resolves; a structural scoliosis does
not disappear and therefore needs further assessment. A lumbar scoliosis may be
associated with a prolapsed intervertebral disc. Disappearance of a scoliosis when
sitting suggests that the scoliosis may be secondary to shortening of a leg. Idiopathic
scoliosis leads to short stature with the trunk short in proportion to the limbs.
Ask the patient to extend their lower back. An increased kyphosis which is regular and
mobile is found in postural kyphosis. Common causes of a fixed regular kyphosis are
senile kyphosis (may be associated with osteoporosis, osteomalacia or pathological
fracture), Scheuermann's disease and ankylosing spondylitis. Common causes of an
angular kyphosis, with a gibbus or prominent vertebral spine include fracture,
tuberculosis or a congenital vertebral abnormality.
Lumbar curvature: flattening or reversal of the normal lumbar lordosis as in a prolapsed
intervertebral disc, osteoarthritis of the spine and ankylosing spondylitis. An increase in
the lumbar curvature may be normal or due to spondylolisthesis, or secondary to an
increased thoracic curvature or a flexion deformity of the hip.
Look for any other abnormalities (eg, café-au-lait spots) which may suggest
neurofibromatosis, a fat pad or hairy patch suggestive of spina bifida, or scarring
suggestive of previous thoracotomy or spinal surgery.
Functional overlay:
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Ask the patient to sit up on the couch. A genuine patient will have to flex the knees
or they will fall back on the couch with pain.
Axial loading: apply pressure to the head. Overlay is suggested if this aggravates
the back pain.
Palpation
Check for bone tenderness of the spine: tenderness may indicate serious pathology
such as infection, fracture or malignancy.
Ask the patient to lean forwards: tenderness between the spines of the lumbar
vertebrae and at the lumbosacral junction and over the lumbar muscles may occur with
prolapsed intervertebral disc and mechanical back pain.
Check for tenderness over the sacroiliac joints. This may also occur in cases of
mechanical back pain and with inflammation of the sacroiliac joints.
A palpable step at the lumbosacral junction may indicate spondylolisthesis.
Percussion
Ask the patient to bend forward. Lightly percuss the spine from the root of the neck to
the sacrum.
Significant pain is a feature of infections, fractures and neoplasms.
An exaggerated response may be a feature of a non-organic problem.
Movements
Flexion:
Observe carefully, as hip flexion can account for apparent motion in a rigid spine.
Flexion may be recorded by the distance between the fingers and the ground
(most normal people can reach within 7 cm of the floor) or the level that the person
can reach (eg, mid-tibia).
The overall flexion is due to a combination of thoracic, lumbar and hip movements
and does not distinguish between them.
Schober's test:
When the spine flexes, the distance between each pair of vertebral spines
increases. Schober's test can be used to provide a quantitative evaluation of
flexion of the lumbar spine.
A tape with a 15 cm mark is placed vertically in the midline upwards from the
level of the dimples at the level of the posterior superior iliac spines). Mark
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the skin at 0 and at 15 cm and then ask the patient to flex as far forward as
they can.
Record where the 15 cm mark on the skin strikes the tape. The increased
distance along the tape is due only to flexion of the lumbar spine and is
normally about 6-7 cm (less than 5 cm should be considered as abnormal).
Flexion in the thoracic spine may be measured with the upper point 30 cm
from the previous zero mark. Thoracic flexion is normally only about 3 cm.
Extension:
Ask the patient to arch their back; pain and restricted extension are particularly
common in a prolapsed intervertebral disc and spondylolysis.
Maximum range is thoracic 25° and lumbar 35°.
Lateral flexion:
Ask the patient to slide their hands down the side of each leg in turn and record
the point reached, either in centimetres from the floor or the position that the
fingers reach on the legs.
The contributions of the thoracic and lumbar spine are usually equal.
Rotation:
The patient should be seated and asked to twist round to each side.
The normal range is 40° and is almost entirely thoracic; lumbar contribution is 5°
or less.
Performing the test with the patient's arms folded across their chest gives a more
accurate assessment.
Suspected prolapsed intervertebral disc
Straight leg raising:
Passively flex the thigh with extended leg while the patient is supine. Dorsiflexion
of the foot helps to elicit pain. Stop when the patient complains of back or leg pain
(hamstring tightness is not relevant). The test is negative if there is no pain.
Paraesthesiae or pain in root distribution is very significant, indicating nerve root
irritation.
A positive result on the same side as the pain is said to be about 80% sensitive
but only 40% specific; a positive result with the unaffected leg is said to be only
25% sensitive but 75% specific.
Back pain suggests, but is not indicative of, a central disc prolapse and leg pain
suggests a lateral protrusion. Pain must be below the knee if the roots of the
sciatic nerve are involved.
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Lower the leg until pain disappears and then dorsiflex the foot. This increases
tension on the nerve roots, aggravating any pain or paraesthesiae (positive sciatic
stretch test).
Bowstring test:
Once the level of pain has been reached, flex the knee slightly and apply firm
pressure with the thumb in the popliteal fossa over the stretched tibial nerve.
Radiating pain and paraesthesiae suggest nerve root irritation.
Lasegue's sign:
With the patient supine and hip flexed, dorsiflexion of the ankle causes pain or
muscle spasm in the posterior thigh if there is lumbar root or sciatic nerve irritation.
Femoral stretch test:
With the patient prone and the anterior thigh fixed to the couch, flex each knee in
turn. This causes pain in the appropriate distributions by stretching the femoral
nerve roots in L2-L4.
The pain produced is normally aggravated by extension of the hip.
The test is positive if pain is felt in the anterior compartment of the thigh.
Neurological involvement
Test the patellar (L3, L4) and Achilles (L5, S1) reflexes.
Root pressure from a disc may affect myotomes and dermatomes in a selective fashion;
record any muscle wasting (compare girths of calf and thigh muscles):
Myotomes:
L2, L3: hip flexion and internal rotation.
L4, L5: hip extension and external rotation.
L3, L4: knee extension.
L5, S1: knee flexion.
L4, L5: ankle dorsiflexion.
S1, S2: ankle plantar flexion.
L4: ankle inversion.
L5, S1: ankle eversion.
Dermatomes:
L2: upper thigh.
L3: knee.
L4: medial aspect of the leg.
L5: lateral aspect of the leg, medial side of the dorsum of the foot.
S1: lateral aspect of the foot, the heel and most of the sole.
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S2: posterior aspect of the thigh.
S3-S5: concentric rings around the anus, the outermost of which is S3.
Suspected thoracic cord compression
Thoracic cord compression may be assessed by testing the abdominal reflexes. Use a
blunt object to stroke the skin in each paraumbilical skin quadrant.
Failure of the umbilicus to twitch in the direction of the stimulated quadrant suggests
cord compression on that side at the appropriate level.
The muscles of the upper quadrants are supplied by T7-T10 and the lower quadrants
by T10-L1.
Suspected thoracic motor root dysfunction
Ask the patient to place their hands behind their head, flex their knees and sit up.
Movement of the umbilicus to one side suggests a weakness of the abdominal muscles
on the opposite side.
Possible causes of nerve root compression include an osteophyte, tumour or spinal
dysraphism.
Chest expansion
Chest expansion may be particularly relevant in suspected cases of ankylosing
spondylitis.
Check the patient's chest expansion at the level of the fourth interspace.
The normal range for an adult of average build is at least 6 cm.
Less than 2.5 cm is considered abnormal.
Abdominal and cardiovascular examination
Depending on individual presentation, it is essential to consider non-musculoskeletal
causes of back pain - eg, urological, gynaecological, gastrointestinal, aortic aneurysm.
Assessment of the peripheral vascular system in lower limbs may be important with a
patient presenting with leg symptoms, to evaluate peripheral vascular disease.
Consider primary malignancy sites which may have metastasised to the spine,
especially breast cancer, thyroid cancer, renal cancer, prostate cancer and lung cancer.
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Hip and sacroiliac joint examination
Check the hip joints for range of movement and for pain or limitation. Hip problems may
present with predominantly back and buttock pain as well as pain in the groin. A loss of
range on internal rotation of the hip is often the earliest sign of hip disease.
Osteoarthritis of the hip may be clinically confused with low back pain, particularly a
prolapsed intervertebral disc.
To assess the sacroiliac joint:
With the patient lying prone, elicit sacroiliac joint tenderness by applying firm
pressure with one hand over the sacrum and the upper natal cleft.
Then flex the hip and knee and then adduct the hip. Pain may indicate sacroiliac
joint involvement, such as in ankylosing spondylitis or Reiter's syndrome.