THE PHYSICAL

EXAMINATION
of
THE SPINE

Charles A Simanjuntak, dr, SpOT(K), MPd

PSPD Universitas Jambi

Introduction
Careful

Physical Examination is potentially

the most valuable service a physician can
provide to the patient. ( OKU Spine : 2004 )

Complete

exam :
Correct diagnosis
Magnitude of the problem
Determine appropriate Treatment

Introduction
Advances
PE

in imaging technique MRI, CT etc

Less important ?
Time consuming ?

MRI,

CT : high false positive rate for spinal

disease
Risk : attributing asymptomatic lesion
Fail to identify actual problem source

History & PE Determine nature

Radiografic study confirm D/

& extent

OVERVIEW
LOOK

inspection
FEEL

palpation
MOVE

active & passive

movements

INTRODUCTION
Smile,

eye contact and shake hands

Explain
Entire

in simple terms

back & legs exposed

Patient

standing upright (initially)

EXAMINATION

Suitably undressed
Usually down to underwear
Start with the patient standing
Then lying prone
Finally lying supine

EXAMINATION
General inspection
in front, beside & behind the patient,
assess:
Posture
indicate normal curvatures of the spine
Bony

deformities

kyphosis, lordosis or scoliosis

spina-bifida
Pigmentation, hair on sacral area

General Inspection

General Inspection

General Inspection

EXAMINATION : STANDING

Look

Scars
: previous surgery
Lumps
: abscess, tumour (e.g.
sacral lipoma),
prominent
paravertebral muscle
spasm
Sinuses : deep infection
Caf au lait : spots / nodules:
Neurofibromatosis
Hairy patch: (spinal dysraphism)

EXAMINATION : STANDING

Look :

Low hairline due to short neck

Klippel-Feil syndrome may be
associated with Sprengel shoulder
(undescended scapula)
Downs / Morquio syndromes
(Atlanto-axial instability)
Asymmetry of shoulder height /
trunk balance scoliosis (lateral
curvature with rotational deformity
of vertebral bodies)

EXAMINATION : STANDING
Look :

Leg length discrepancy

Nerve Root Tension
(consistently stands with one knee
bent in spite of equal leg lengths, as
knee flexion relieves the pull on the
nerve roots)
Lateral deviation of spine (list or tilt)
prolapsed intervertebral disc
nerve root compression
Associated anomalies of hands/feet
(syndactyly, pes cavus; may be part of
a syndrome)
Kyphosis and lordosis

EXAMINATION : STANDING
Look :

Round backing / hunched

shoulders:
Schuermanns disease/kyphosis
Gibbus (kyphos):
acute angular deformity with bony
prominence, e.g. tuberculous
vertebral collapse
Observe gait

EXAMINATION :STANDING

Feel :

Tenderness: may be bony,

intervertebral or paravertebral
Bony prominence or steps
spinous processes
using C7 &/or L4-5
as landmarks
facet joints
approx. 2cm lateral to spinous

processes

EXAMINATION : STANDING

Feel :
assess alignment, mobility &
tenderness of:
transverse processes of
vertebrae
lateral to spinous processes

EXAMINATION : STANDING
Measurement

step of sign
Schober test

EXAMINATION : STANDING
Movement :
active movements :

assess ROM of the spine

describe:

flexion

where movement takes place

what determines direction of movement
what structures limit this movement
significance of IV disc thickness
sagittal arrangement of facet joints
limited by ligaments & muscles

extension

EXAMINATION : STANDING
Movement :

Flexion:

Ensure spinal rather than hip flexion

(by marking two spots about 10cm apart on the

patients lumbar spine)

these should separate by a further 5cm

on flexion
Forward bend test:
scoliosis disappears on forward bending
postural scoliosis disappears on sitting,
leg shortening Scoliosis secondary to
nerve root compression disappear after
resolution (spontaneous or surgical), i.e.
sciatic scoliosis

Movement
:
EXAMINATION :

Extention
STANDING
To arch backwards

(beware of bending knees)

The wall test

will unmask even small fixed flexion

deformities (to stand with back against a wall
heels, buttocks, shoulders and occiput
touch the wall

Lateral flexion

(to run hand down ipsilateral thigh on one

side, and then the other) Asymmetry in
ROM is clinically more significant than actual
ROM

EXAMINATION
: STANDING
Movement
:
Extention
Rotation

most rotation occurs in the

thoracic spine, this should not be
reduced in lumbo-sacral disease)

Rib cage excursion

about 7cm between full

inspiration and full expiration)

EXAMINATION
CERVICAL SPINE
Flexion:

Most people can get their chin on their

suprasternal notch

No flexion in thoracic spine, because splinted by ribcage

Extension:

should allow nose or forehead to be parallel to

ceiling
Rotation:
cheek parallel to shoulder
Rotation occurs mainly at atlantoaxial joint (C1/C2)
No rotation in lumbar spine, because facet joints are
vertical

Lateral

flexion:

very variable, and first movement to be restricted

in arthritis

EXAMINATION
STANDING or SITTING
Passive Movement
physically move patient through full
range of movement
feel for resistance and crepitus
over-pressure may sometimes be
applied at end range of movement

EXAMINATION
2. LYING PRONE

Look :
Watch the patient climb on the
examination couch

Feel :
Focal spinal tenderness
Assess sensation on back of whole leg if
worried about cauda equina syndrome,
perianal sensation may also be assessed
here
Check popliteal and posterior tibial pulses

EXAMINATION
2. LYING PRONE

Movement :
Femoral nerve stretch

(Either acutely flex the knee with the

thigh resting on the couch, or extend the
hip with the knee in moderate flexion)
If pain is elicited, there is a positive nerve
stretch test

Assess hip rotation and ankle

reflexes with the knee at 90 degrees of

flexion

EXAMINATION
2. LYING SUPINE

Look

:
Watch the patient turn over onto his/her back
Feel :
Sensation can be tested here or at the end, in
the neurological examination

Reflexes

Movement :

physiologic

pathologic

Assess hip/knee mobility

Straight Leg Raise (SLR sciatic nerve root
irritation
(increased by dorsiflexion of the ankle)

EXAMINATION
2. LYING SUPINE
Movement :

Lasegues test :

Bowstringing test :
With hip flexed to 90o, extend the
knee as far as the patient tolerates.
Pressure applied to the hamstrings
with the thumb will immediately
cause pain if there is nerve root
irritation

Signs of nerve root

compression
Standard full neurological examination of
both lower limbs :
tone, power (MRC grading)
sensation (light touch, pinprick &
proprioceptive if indicated)
reflexes (physiologic and patologic)
an anatomical distribution
[dermatome(s) or myotome(s)]

Neurological Examination
Objectives

Determine if defect is present

Localize the level of the deficit
Include

Sensory
Motor
Reflex

Neurological Examination

Sensory examination
Explain,

eyes closed
Examine : touch, 2 point discrimination,
proprioceptive.
Sensory dermatomes, compare each
opposite

Sensory Dermatome

Muscle Power Grading

0

- complete paralysis
1 - flicker of contraction possible
2 - movement is possible when gravity is
excluded
3 - movement is possible against gravity
4 - movement is possible against gravity
+ some resistance
5 - normal power

Neurological Examination
Motor
examination
Muscle

grading
Compare each side

Cervical :
Scapular

C4

Deltoid & Biceps

C5

Wrist extension & supination

C6

Wrist flexion & Pronation

C7

Neurological Examination
Motor
examination
Lumbo-sacral
Hip flexor
Hip extensor

L 1,2,3
S1

Knee flexor
Knee extensor

L 4,5, S1,2
L 2,3,4

Ankle flexor
Ankle extensor

S1
L5

Reflexes
Biceps

Brachioradialis

Triceps

Hoffman

Reflexes
Knee Patellar

Achilles

Babinsky

TEST

SLR : sitting
& supine

COMMENTS

Must produce radicular symptom in the

distribution of the provoked root, for

sciatic nerve , that means pain distal
to knee

SLR : sitting
& supine

SLR radiculopathy aggravated by ankle

dorsoflexion

Contralateral
SLR

Well-leg SLR puts tension on involved root

from opposite direction

Kernig's
test

The neck is flexed chin to chest. The hip is

flexed to 90, and then the leg is the
extended similar to SLR; radiculopathy is

PROVOCATIVE TESTS
TEST

COMMENTS

Bowstring sign

SLR radiculopathy aggravated by applying

pressure over popliteal fossa.

Femoral stretch
test

Prone patient; examiner stretch femoral nerve

roots to test L2-L4 irritation

Nafziger's test

Compression of neck vein for 10 s with patient

lying supine ;
coughing then reproduces radiculopathy

Milgram's test

Patient raises both legs off the examining table

and hold this
position for 30 s; radiculopathy maybe
reproduced