Physical Examination of the Spine

Daniel R. Possley

Andrew J. Schoenfeld

Introduction

A thorough history and physical examination is the cornerstone to the effective evaluation of spinal disorders. While modern imaging modalities, such as computed tomography and magnetic resonance imaging, can clearly delineate pathology involving the osseous and soft tissue structures of the spine, it is the history and examination that correlates imaging findings with the patient’s complaints and functional limitations. A thorough and efficient approach to history taking and focused examination of the spine are vital skills for any clinical spine specialist. The history will provide details of the patient’s symptoms and perceived limitations which help modify the differential diagnosis. Effective identification of the factors responsible for pain and disability as well as those interfering with recovery, are the principal goals of the physical examination. Focused testing during the examination can further narrow the differential and, in the outpatient setting, may direct what additional imaging modalities are required. Confirmation of the diagnosis will allow for an appropriate intervention or enable the formulation of a comprehensive and personalized treatment plan.

Spine surgeons are most frequently asked to evaluate patients in the outpatient clinic or the hospital setting. In the hospital environment, evaluation may occur in the acute setting of the emergency department or in clinical consultation on the wards. The history and examination should be tailored to the clinical nuances of the location in which the surgeon is asked to evaluate a patient. For example, in the outpatient setting where patients typically present with chronic or subacute issues, a greater emphasis may be placed on provocative testing that can reproduce patient symptoms and localize or differentiate their spinal disorder. In the more acute atmosphere of the hospital, patient injuries or active comorbidities might limit what examination maneuvers can effectively be performed and the evaluation is typically geared toward screening for injuries or understanding the physical manifestation of known spinal issues. The general approach and sequence of the examination, however, remains the same regardless of the clinical setting in which the history and physical examination is conducted. This chapter presents a standardized approach to the thorough examination of patients with spinal disorders in both the outpatient clinic and hospital environment.

Examination in the Outpatient Clinic

Inspection

The physical examination in the outpatient setting is typically comprehensive and should regularly follow several steps. In the office setting, more emphasis may be placed on provocative tests geared toward reproducing the patient’s symptoms or complaints. The overall goal is to localize the patient’s issue to spinal pathology and narrow the differential diagnosis which may include axial and mechanical back pain, radiculopathy, myelopathy, fracture, or some other pathologic process.

Upon greeting the patient, observation begins with evaluation of posture, demeanor, and character. Observation of standing trunk and appendicular alignment is performed, including assessment for muscle spasm and alterations in normal cervical and lumbar lordosis as well as thoracic kyphosis (Fig. 1.1). Head, shoulder, and pelvic height and tilt is assessed as well as observation of any scars, contractures, skin changes, atrophy, and/or hypertrophy. Gait assessment can be completed as the patient enters the room or more formally as part of the examination. Specific gait patterns can represent certain neurologic disorders. Gait patterns suggestive of neurologic deficits include a stochastic gait or associated footdrop. A wide-based gait may be indicative of a myelopathic process (Table 1.1). An antalgic gait is generally associated with lower extremity pathology, but may also present within the constellation of symptoms associated with referred back pain or radicular issues.

Figure 1.1 The alignment of the adult human spine as seen from the lateral view. Lordotic posture of the cervical and lumbar spinal segments is considered normal.

TABLE 1.1 COMMON ASSOCIATIONS BETWEEN ABNORMAL GAIT PATTERNS AND SPINAL PATHOLOGY

Wide-based gait	Myelopathy
Locked knee gait	Quadriceps weakness (L2–L4 pathology)
Footdrop/steppage	Loss of ankle dorsiflexion from weakness of tibialis anterior or extensor hallucis (L4–L5)
Flatfoot/slapfoot	Loss of calf plantar flexion from weakness of the gastrocnemius/soleus (S1–S2)
Abductor lurch	Abductor weakness due to pathology involving the gluteus medius (L5)

Spinal range of motion should next be assessed within the cervical, thoracic, and lumbar segments. Gross movements in flexion, extension, side bending, and rotation as well as hip, knee, shoulder, and scapular motion are documented. Spinal curve examination can be performed using a forward flexion maneuver (e.g., flexion at the lumbosacral articulation), noting differences in rib hump or paraspinal muscle prominence. Range of motion testing may reproduce symptoms, while symmetry of movement, balance, and motor control should also be assessed. Reproduction of pain with passive hip, knee, and/or shoulder motion can direct attention to these joints as primary pain generators vis-à-vis the spine.

Palpation

The entire spine should be palpated looking for areas of tenderness. Anteriorly, assess the thyroid gland and surrounding soft tissues for tenderness, masses, and muscle spasm. The clavicles, supraclavicular fossae, and scapulae should be evaluated for pain, masses, or cervical rib tenderness. Posteriorly, both midline and paraspinal soft tissues should be palpated separately, noting areas of tenderness and spinous process widening or step off from occiput to coccyx, including the sacroiliac joints. The facets in the subaxial cervical spine and lumbar region can be independent pain generators with reproducible distributions of referred pain. Facet joints identified as possible pain generators using palpation can be further interrogated by performing a resisted extension-based maneuver in the painful location. Areas of local and widespread tenderness as well as muscle spasm should be distinguished.

Transition from the lordotic cervical spine to the kyphotic thoracic region occurs at the first large spinous process, or vertebra prominens, found at C7. This is a landmark for the cervicothoracic junction. Palpation must extend to the costovertebral junction and rib angles at thoracic levels. The scapular spine is consistent with the T3 level and inferior border of the scapulae lies at T7. Distally, the iliac crests, sacroiliac joints, sacrum, greater trochanters, and ischial tuberosities should also be palpated. The superior borders of the iliac crests are parallel to the disk space of L4–L5.

Neurovascular

Knowledge of dermatomal patterns and their anatomical landmarks according to the 31 pairs of spinal nerves is essential (Fig. 1.2). Bilateral sensation to light touch via fingertip and pin-prick testing with a broken cotton-tipped applicator or exposed end of a paperclip can delineate a dermatomal distribution of nerve root pathology. Diminished sensation involving overlapping dermatomes or multiple distributions (e.g., stocking glove paresthesias) usually indicate extraspinal pathology and may be representative of peripheral nerve entrapment, diabetic neuropathy, or piriformis syndrome. Further testing consisting of proprioception, vibration, and temperature
perception can be completed if there is concern for a central nervous system process or to help localize the area of involvement. Dermatomes have a certain amount of overlapping innervation between spinal nerve roots.

Figure 1.2 Anterior and posterior sensory dermatomes. (Reprinted with permission from Sharon Jensen, Nursing Health Assessment. 2nd ed. Philadelphia, PA: Wolters Kluwer Health, 2014.)

The nerve roots of the spine exit under the matching pedicle (L5 nerve under L5 pedicle) in the thoracic, lumbar, and sacral regions. Cervical nerve roots exit above their corresponding numbered vertebrae, including a C8 nerve root that exits below the C7 body. The orientation of the nerve root in the cervical spine is unique as well. Here the root lays in a more horizontal fashion. Thus, a central and foraminal disk protrusion will affect the same nerve root while a lumbar nerve root is more vertically oriented. In the lumbar spine, a paracentral disk herniation will affect the traversing nerve root, while a foraminal disk herniation will affect the exiting root. The examination of peripheral pulses is performed in the extremities. Examination of pedal pulses, skin color, and hair growth is necessary to assess for possible peripheral vascular disease, particularly in patients with claudication symptoms. Trophic skin changes, diffuse hair loss and diminished, or nonpalpable, pulses may be indicative of an underlying vascular disease.

Sensation

Bilateral sensory testing is typically performed within the C5–T1 dermatomes in the upper extremities, T2–T12 in the thoracic levels, and L1–S1 in the lumbosacral levels (Fig. 1.2). Dermatomal innervations may overlap and patients can have unique sensory distributions. The C2 dermatome generally covers the area 1 cm lateral to the occipital protuberance at the skull base. The C3 dermatome covers the supraclavicular fossa at the midclavicle. The C4 dermatome lies over the acromioclavicular joint. The T4 dermatome innervates the chest wall at the level of the nipples. T7 innervates the chest wall at the level of the xiphoid process and the inferior border of the sternum. T10 innervates the skin along the abdominal wall at the level of the umbilicus. S3, S4, and S5 innervate the skin around the perianal region, forming concentric rings with S5 in the center and S3 at the gluteal fold (Fig. 1.3).

Figure 1.3 Sacral dermatomal distributions involving the perineal and perianal region. (From Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. 2nd ed. Philadelphia, PA: WB Saunders, 1998.)

Motor

The motor examination begins with assessment of muscle shape, size, and symmetry. Knowledge of myotomes enables the examiner to challenge strength in specific distributions and identify deficits that may be correlated to pathologic processes (Figs. 1.4 and 1.5). The myotomes typically assessed on a general spinal examination include C5–T1 in the upper extremities and L2–S1 in the lower extremities. These myotomes can be evaluated efficiently using the following tests:

C5—Testing the deltoid with shoulder abduction
C6—Testing the wrist extensors
C7—Testing the triceps, wrist flexors, and finger extensors (having the patient make “Figure 1.7” with their outstretched arm)
C8—Finger flexors
T1—Abduction and adduction of the fingers (intrinsic musculature of the hand)
L2—Testing hip flexion
L3—Testing knee extension
L4—Testing ankle dorsiflexion
L5—Testing great toe dorsiflexion
S1—Testing ankle plantar flexion

If the patient complies with a complete examination without deficit, they receive a grade of normal strength (5/5) at each level, and no further strength testing is performed for that muscle group. The grade is related to strength at maximal effort and does not reflect sustained effort. Thus, a patient whose examination reveals “giving way” for whatever reason should have a grade supplied relative to the maximal strength prior to the “giving way” event.

Grading of motor testing uses the following scale:

Grade 5: Signifies full strength with the ability to move against active resistance.
Grade 4: Signifies the ability of the muscle to move against some, but not full, resistance.
Grade 3: Signifies movement against gravity alone without any added resistance.
Grade 2: Signifies the ability to move after gravity has been eliminated.
Grade 1: Signifies visible contraction of the muscle without the ability to move.
Grade 0: Signifies no visible motor function.

Detection of impairment, or weakness, can be best elucidated with repetitive testing comparing bilateral myotomes and muscle groups to assist in grading. Further assessment of muscle tone, coordination, and involuntary action completes the motor examination. Muscles can be hypotonic or hypertonic and tested via passive motion. Decreased tone (hypotonia) is present in lower motor neuron lesions, spinal shock, and some cerebellar lesions. Increased tone (hypertonia) is revealed as spasticity or rigidity. Lower motor neuron injury is characterized by decreased tone/flaccidity while increased tone/spasticity is associated with upper motor neuron disease. In the setting of radiculopathy, only the myotomes of the ipsilateral extremity are affected. In the presence of myelopathy or myeloradiculopathy (mixed pattern), the bilateral extremities can

be affected. Other clinical characteristics that differentiate radiculopathy from myelopathy on examination are described in Table 1.2.

Figure 1.4 Sensory, motor, and reflex testing of the C5–T1 nerve roots. (From Klein JD, Garfin SR. History and physical examination. In: Weinstein JN, Rydevik BL, Sonntag VKG, eds. Essentials of the Spine. New York, NY: Raven Press, 1995:71–95.)

Figure 1.5 Sensory, motor, and reflex testing of the L4–S1 nerve roots. (From Klein JD, Garfin SR. History and physical examination. In: Weinstein JN, Rydevik BL, Sonntag VKG, eds. Essentials of the Spine. New York, NY: Raven Press, 1995:71–95.)

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