Spine Evaluation, Clinical Examination, and Imaging

Spine Evaluation, Clinical Examination, and Imaging

Themistocles S. Protopsaltis, MD, FAAOS

Karan S. Patel, MD

Dr. Protopsaltis or an immediate family member has received royalties from Altus; serves as a paid consultant to or is an employee of Globus Medica, Medicrea, Medtronic, Nuvasive, and Stryker; and has stock or stock options held in Spine Align and Torus Medical. Neither Dr. Patel nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.


Evaluating patients with complaints of back and neck pain is challenging because of the complex nature of spine anatomy and pathophysiology. Despite advancements in imaging technology, key aspects of a spine evaluation involve obtaining a thorough history and performing a detailed physical examination. A complete history and neurologic physical examination can help identify causative factors of a patient’s complaint and guide appropriate treatment.


The patient history is an important component of patient evaluation. A thorough history can aid in developing a differential diagnosis, identifying the cause of a patient’s symptoms, and determining an appropriate treatment plan.1 When evaluating a patient, it is important to identify the nature of the complaint; the onset and duration of symptoms; the intensity, location, and radiation of any pain, numbness, or paresthesia; and any alleviating and aggravating factors.2 Patients may present after receiving prior testing and treatments, so obtaining such information is key to avoid repeating unnecessary diagnostic and treatment modalities. Finally, understanding the degree of pain and disability experienced by patients and learning the circumstances surrounding their symptoms (eg, work-related injury) can identify potential psychosocial factors that may affect their recovery.1

A thorough history can be used to describe back and neck pain in a number of different ways. It can be described as mechanical pain if it is associated with activity, progressively worsens over the course of a day, and improves with rest. Pain that occurs independent of activity, is constant, worsens at night, and is not relieved with rest is nonmechanical pain and may indicate the presence of infection or malignancy.3 Pain can also be described as axial pain if it is diffuse and referred to the cervical, thoracic, or lumbar region of the back. Axial pain can be caused by pathology of musculotendinous structures, facet joints, anulus fibrosus, and abdominal visceral structures that refer pain to the back.1 Radicular pain is radiating pain that occurs in a typical dermatomal distribution and may be associated with numbness, paresthesia, and weakness in a myotomal distribution and tension signs on physical examination. Such symptoms indicate nerve root compression, which may occur because of pathologies such as disk herniation or spinal
canal and foraminal stenosis.3 Patients who present with vague pain that does not follow a specific pattern and complain of progressive motor and sensory deficits, such as hand paresthesia, a slow broad-based gait, and difficulty with upper extremity fine motor tasks (eg, fastening buttons, handwriting), may have myelopathy due to spinal cord compression.4

For patients who present with complaints of low back and leg pain, it is important to use the history to differentiate between hip and lumbar spine pathology. Hip pain is generally localized to the groin, occurs immediately with walking, and is aggravated by dressing the symptomatic leg or getting in and out of a car.5 Lower extremity pain originating in the lumbar spine often radiates below the knee, can be bilateral, and can be associated with tingling or numbness.5

The location of a patient’s pain or radiating symptoms can be used to determine the affected spinal level. Symptoms that follow a specific dermatomal or myotomal pattern may indicate involvement of the corresponding nerve root. The dermatome patterns currently considered standard were first described in a 1948 study6 (Figure 1). Clinically, however, patients may present with symptoms that vary from these standards. A 2019 study of cervical radiculopathy compared patient-reported patterns of radicular symptoms with a standard textbook dermatomal map and found only 54% correlation between the two.7 This finding can be attributed to anatomic variations among patients, variations in the severity of a patient’s disease and symptoms, and to the fact that the standard dermatome and myotome maps may not fully account for overlapping innervations.8

A comprehensive history should identify the presence of red flags. These are symptoms and findings that can be used to recognize serious conditions such as infection, tumor, cauda equina syndrome, and fractures1 (Table 1). Although many red flags, such as unintentional weight loss, night pain, and age older than 50 years, have been reported to suggest a diagnosis of malignancy, a systematic review identified a history of malignancy as the red flag finding with the highest posttest probability for detecting spinal malignancy.9 Similarly, the presence of multiple red flags, such as older age, prolonged use of corticosteroids, and history of trauma, had the highest posttest probability for detecting spinal fractures.9 Spinal infections often occur because of hematogenous spread from other regions and should be considered when a history of a recent infection is identified.1,10 Cauda equina syndrome should be considered when a history of progressive bilateral lower extremity weakness, saddle anesthesia, and bowel or bladder dysfunction, particularly urinary retention, is revealed in the patient history.1,10 A detailed history can help formulate a focused differential diagnosis and guide the physical examination.

Physical Examination

A well-performed physical examination can help narrow the differential diagnosis and identify findings that can further clarify the cause of a patient’s symptoms. A spine physical examination should follow the usual pattern and include inspection, which includes gait assessment, palpation, and a neurologic examination that includes provocative maneuvers.1


The physical examination begins with inspection from the moment a physician first sees a patient. Simply observing a patient and paying careful attention to their sitting and standing posture and head position can offer information about their overall spinal alignment.11 Typical spine sagittal alignment includes cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacrococcygeal kyphosis.1 These can be altered in patients with spinal deformity and sagittal malalignment. Asymmetry in bony structures such as the rib cage and scapula, obliquity of the pelvis, and a limb-length discrepancy can also indicate underlying deformity. Skin findings such as café au lait spots and midline dimples and tufts of hair may indicate underlying neurofibromatosis or occult spinal dysraphism.3 Furthermore, muscle atrophy and asymmetry may be noticeable in patients with nerve root pathology and underlying neurologic impairment.


Gait assessment can offer insight into a patient’s underlying pathology. Observing a patient ambulate on their heels and then on their toes can help assess for pathology involving the L4/L5 (tibialis anterior muscles) and S1 (gastrocnemius-soleus complex) nerve roots, respectively. Tandem gait testing (heel-to-toe walking) can assess for coordination, balance, and myelopathy. Similarly, observing a slow, wide-based gait may indicate myelopathy or cerebellar involvement, whereas a high steppage gait may indicate a foot drop or L4/L5 pathology. The slow gait often observed in patients with myelopathy occurs because it takes these patients more time to fully recruit muscles and achieve peak electromyography during the gait cycle than in healthy control patients.12 An antalgic gait may indicate underlying hip osteoarthritis and can be used to help differentiate between hip and lumbar spine pathology.

Range of Motion

Given the complexity in movement of the spine, as opposed to movement of peripheral joints such as the knee, numerous measurement techniques have been developed to assess range of motion. This has resulted in the reporting of a wide range of normal values for cervical and lumbar range of motion13,14,15 (Table 2). Despite the variability in normal values, assessing motion can be useful. It can be expected to decrease with age and degenerative disease. Pain with certain movements such as lateral bending and extension may indicate foraminal and facet joint pathology, respectively. In addition to measuring spine range of motion, hip range of motion should also be evaluated because a painful and restricted hip range of motion is a major indicator of underlying hip pathology.5


Palpation of spinous processes should start at the base of the occiput and continue down to the sacrum. Midline tenderness should be differentiated from tenderness in the surrounding soft-tissue structures. A palpable step-off of the spinous process in the lumbar spine may indicate underlying spondylolisthesis. Palpation of the sacroiliac joints and greater trochanters may help identify pathology that may also be a source of back pain.11

Neurologic Examination

A thorough neurologic examination makes up the core of a spine physical examination. Nerve root and spinal cord pathologies such as radiculopathy and myelopathy are often the most common neurologic manifestations of spine pathology, so identifying them with a neurologic examination is important. A neurologic examination should begin with a quick examination of cranial nerves II through XII because this can offer insight into any preexisting brain stem or upper motor neuron pathology.

The sensory examination is a key component of the neurologic examination, and it requires a thorough understanding of the sensory dermatomes (Figure 1). Because four distinct sensations have defined anatomic pathways in the spinal cord, a thorough examination should assess all four. Sensation should be assessed in dermatomal patterns to light touch with cotton wool, pinprick with the sharp end of cotton swab, proprioception with a low-frequency tuning fork, and temperature with a metal reflex hammer. Sensory deficits in a dermatomal distribution could indicate nerve root pathology, whereas deficits in multiple dermatomes could suggest a peripheral neuropathy.1,16 A 2021 study evaluating the efficacy of sensory tests reported that the combination of light touch and pinprick testing was adequate to identify abnormal sensory findings in 88% of patients with known lumbar radiculopathy and disk herniations.17

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May 1, 2023 | Posted by in ORTHOPEDIC | Comments Off on Spine Evaluation, Clinical Examination, and Imaging

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