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288
Table 27.7 Gait assessment
Lesion Cause Gait
UMNL Unilateral hemiplegia
Bilateral paraplegia
LMNL Peripheral neuropathy High Steppage
Cerebellar Archicerebellum
Neocerebellum
Extrapyramidal Parkinsonism
chorea
A. A. M. Ezzat and H. A. B. Gouda
Circumduction
Scissoring
Drunken Wide base deviation/Zigzag
Short Steppage or Dancing gate
• Feet separation = Wide base: (High Steppage gait: sensory ataxia. No
high Steppage gait: Cerebellar ataxia).
• Others: Waddling: Myopathy.
B) Asymmetrical:
• Foot drop: Radiculopathy L5/Common peroneal nerve injury: Pyramidal
tract lesion.
• Pain Trauma: Arthritis.
• Bone deformity: Short limb or after surgery.
• Hemiplegia.
H) Others
• Inspect for deformities: Scars, Scoliosis or Kyphosis.
• Examine the back and palpate spinous processes, any abnormal swelling,
any tender points.
• Examine range of movement of the neck and lumbar vertebrae.
Chapter 28
Examination oftheSpine
KhaledSaoud
Abstract With the presence of advanced investigations nowadays, no single diag-
nostic modality can replace a careful history tacking and thorough examination of
the spine on reaching exact diagnosis of patient condition. Since clinical picture
varies according to the affected spine level, we divided local examination into cervical and dorsolumber spine examination.
Keywords Spine · Nerves · Clinical · Examination · Sheet · Neurovascular ·
Psycho-social · Gait
With the presence of advanced investigations nowadays, no single diagnostic modality can replace a careful history tacking and thorough examination of the spine on
reaching exact diagnosis of patient condition.
Since clinical picture varies according to the affected spine level, we divided
local examination into cervical and dorsolumber spine examination.
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 is essential to assess the cause, any associated psychological difculties (e.g. depression, anxiety or somatization disorder), and any functional impairment, including restrictions with work, leisure and domestic activities.
General Examination oftheSpine
The examination should begin as soon as you rst 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 specic tests may help to differentiate
between physical and functional causes for the patient’s symptoms.
K. Saoud (*)
Faculty of Medicine, Ain Shams University, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_28
289© The Author(s), under exclusive license to Springer Nature
290
K. Saoud
Inspection
Examination of any localized 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 anesthesia, urinary dysfunction
and bowel disturbances, and rectal examination may reveal loss of anal tone and
sensation).
Movement
The normal range of movements 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 reexes 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 stenosis (see
articles on Cardiovascular History and Examination and Examining the Pulse).
28 Examination oftheSpine
291
Psychosocial Factors (Table28.1)
The assessment should include psychological, occupational and socio-economic
factors, which may either play a role in the cause of back problems, or adversely
affected as a result of back problems.
Table 28.1 The 5 categories and 8 nonorganic signs of Waddell score
Nonorganic
Categories
Tenderness Supercial Tenderness not related to a particular skeletal or neuromuscular
Simulation test Axial loading Back pain is reported when the shoulders and pelvis are
Distraction
tests
Regional
disturbances
Overreaction Sensory Include diminished sensation to light touch, pinprick or other
tests Nonorganic signs
structure; may be either supercial or nonanatomic
Supercial The skin in the lumbar region is tender to light
pinch over a wide area not associated with the distribution of a
posterior primary ramus
Nonanatornic Deep tenderness, which is not localized to one structure, is felt
over a wide area and often extends to the thoracic spine,
sacrum, or pelvis
These tests give the patient the impression that a particular
examination is being carried out when in fact it is not
Low back pain is reported when the examiner presses down on
the top of the patient’s head; neck pain is common and should
not be considered indicative of a nonorganic sign
passively rotated in the same plane as the patient stands
relaxed with the feet together; in the presence of root irritation,
leg pain may be produced and should not be considered
indicative of a nonorganic sign
Rotation A positive physical nding is demonstrated in the routine
manner, and this nding is then checked while the patient’s
attention is distracted; a nonorganic component may be present
if the nding disappears when the patient is distracted
Straight leg
raising
Weakness Demonstrated on testing by a partial cogwheel “giving way” of
The examiner lifts the patient’s foot as when testing the plantar
reex in the sitting position; a nonorganic component may be
present if the leg is lifted higher than when tested in the supine
position
Dysfunction (e.g., sensory, motor) involving a widespread
region of body parts in a manner that cannot be explained
based on anatomy; care must be taken to distinguish from
multiple nerve root involvement
many muscle groups that cannot be explained on a localized
neurologic basis
neurologic tests tting a “stocking” rather than a dermatomal
pattern
May take the form of disproportionate verbalization, facial
expression, muscle tension and tremor, collapsing, or sweating;
judgments should be made with caution, minimizing the
examiner’s own emotional reaction
292
K. Saoud
Neck Examination
Examination of the neck is important in the events of trauma (poly-trauma or isolated neck trauma as whiplash injury). Also, in cases of neck pain due to cervical
spondylosis.
Examination would always include full neurological examination of upper and
lower limbs, gait as well as bladder and bowel disturbances “As mentioned before”.
Inspection
• Deformity: may be seen in cervical spondylosis or acute torticollis.
• Instability of the cervical spine: while the patient is sitting check that the patient
can support their head in neutral position.
• Asymmetry, fullness of the supraclavicular fossa in cases of Pancoast tumor,
Torticollis (affected side and chin often tilted to opposite side) or sternomastoid
‘tumor’ in infants.
• Arms and hands: for wasting, fasciculation, motor abnormalities (tone, power),
sensory decits and any indication of thoracic outlet syndrome.
• Lower limb motor or sensory decits may be caused by cervical spinal cord
compression.
Palpation
• Palpate for tenderness, masses or any scars: Posterior in the midline, Lateral,
Supraclavicular- cervical rib, lymph glands, tumors, 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.
• Palpate lateral aspects of vertebrae for masses and tenderness (the most promi-
nent spinous process is T1).
• Paraspinal tenderness radiating into trapezius is common in cervical spondylosis.
• Crepitation: facet joint crepitus may be detectable with exion and extension of
the neck by either palpation or auscultation on either side of cervical spine; facet
joint crepitus is common in cervical spondylosis.
28 Examination oftheSpine
293
Cervical Movement
• Flexion: normal range is 80° with chin able to touch region of sternoclavicu-
lar joint.
• Extension: normal range 50°, so normal for full exion to full extension is 130°,
primarily involves the atlanto-axial and atlanto-occipital joints.
• Lateral exion: normal range is 45° to both sides; restriction of lateral exion is
common in cervical spondylosis. Inability of lateral exion without forward ex-
ion at 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 exion/elbow exion. Reex
changes: biceps.
• Sensory changes: lateral arm.
• C6 nerve root:
• Muscle weakness: elbow exion/wrist extension. Reex changes: biceps/
supinator.
• Sensory changes: lateral forearm, thumb, index nger.
• C7 nerve root:
• Muscle weakness: elbow extension, wrist exion, nger extension. Reex
changes: triceps.
• Sensory changes: middle nger.
• C8 nerve root:
• Muscle weakness: nger exion.
• Sensory changes: medial side lower forearm, ring and little nger.
• T1 nerve root:
• Muscle weakness: nger abduction and adduction. Reex changes: none.
• Sensory changes: medial side upper arm/lower arm.
294
K. Saoud
Thoraco-Lumbar Spine Examination
Low back pain is a very common presentation in general practice. Common causes
include spine pathology, trauma, muscle diseases. Rare caused may include hidden
malignancy or aortic aneurysm. A thorough examination of the spine and lower
limbs are essential.
Inspection
Observe for abnormal gait and posture, which may provide clues as to the nature
and severity of the problem.
Supercial 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 scolio-
sis does not disappear and therefore needs further assessment. A lumber scoliosis
may be associated with a prolapsed intervertebral disc. Disappearance of a sco-
liosis 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 regu-
lar, and mobile is found in postural kyphosis. Common causes of a xed regular
kyphosis are senile kyphosis, and ankylosing spondylitis.
• Lumbar curvature: attening or reversal of the normal lumbar lordosis as in a
prolapsed intervertebral disc, osteoarthritis of the spine and ankylosing spondy-
litis. An increase in the lumbar curvature may be normal or due to spondylolis-
thesis, or secondary to an increased thoracic curvature or a exion deformity of
the hip.
Skin examination is essential: Cafe-au-lait patches, a sign neurobromatosis is
important nding. Tuft of hair over the pelvis may indicate spina bida.
Palpation
Check for bone tenderness of the spine: tenderness may indicate serious pathology
such as infection, fracture or malignancy.
28 Examination oftheSpine
• Ask the patient to lean forwards and palpate the spines and spaces in between.
This would give you clue on alignment. Step may indicate spondylolisthesis.
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 (sacroileitis and sero-negative
rheumatoid arthritis are common causes).
295
Percussion
Ask the patient to bend forward. Lightly percuss the spine from the root of the neck
to the sacrum. Signicant pain is a feature of infections, fractures and neoplasms.
An exaggerated response may be a feature of a non-organic problem.
Movements
Flexion, extension rotation and lateral bending should be examined.
• Flexion: Most normal people can reach within 7 Cm from the oor when exed.
Limitation of exion may be due to muscle spasm or advanced spondylosis or
ankylosing spondylitis.
• Restricted extension occurs in prolapsed lumber disc, lumber spondylosis or
facet joint diseases.
• Rotation is tested while the patient is seated. Normally around 40° can be
reached.
• Lateral bending is tested by asking the patient to slide their hands down the side
of each leg in turn, and record the point reached from the position that the ngers
reach on the legs.
The contributions of the thoracic and lumbar spine are usually equal.
Specic Tests
• Straight leg raising: Passively ex thigh with extended leg while patient is supine.
Dorsiexion of foot helps to elicit pain. Stop when the patient complains of back
or leg pain. The test is negative if there is no pain. Paresthesia or pain in root
distribution is very signicant, indicating nerve root irritation.
• The angle of pain elicited should be recorded.
296
K. Saoud
• Back pain suggests a central disc prolapse, and leg pain suggests a lateral
protrusion.
• Crossed straight leg raising positive test indicate more signicant disease (rais-
ing the asymptomatic leg causes pain in the symptomatic side).
• It is positive in cases of L5 and S1 root compression.
• Femoral stretch test: With the patient prone and the anterior thigh xed to the
couch, ex 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 thigh.
Neurological Involvement
Test the patellar (L3, L4) and Achilles (L5, S1) reexes.
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 exion and internal rotation
• L4, L5: hip extension and external rotation.
• L3, L4: knee extension
• L5, S1: knee exion
• L4, L5: ankle dorsiexion
• S1, S2: ankle plantar exion 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
• S2: posterior aspect of the thigh
• S3-S5: concentric rings around the anus, the outermost of which is
S3Umbilical reex
The reex is absent in cases with upper motor neurons lesion above the level of
thoracic spine. We use blunt object to stroke the skin in each paraumbilical quadrant
of the skin. Normally the umbilicus twitches to the direction of stimulated quadrant.
The muscles of the upper quadrants are supplied by T7-T10, and the lower quadrants by T10-L1.
Chest expansion
28 Examination oftheSpine
297
• Check the patient’s chest expansion at the level of the 4th interspace.
• The normal range for an adult of average build is at least 6cm.
• Less than 2.5cm is considered abnormal.it is affected in cases with cervical cord
injury and in diseases with affection of the movement of rib joints as ankylosing
spondylitis.
Abdominal examination is important especially with non-spine causes of back pain
such as aortic aneurysm and gynecological tumors.
Peripheral pulses should be palpated to rule out vascular claudication.
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 prolapsed intervertebral disc.
Sacroiliac joints
The most commonly used is FABER test, Flexion, Abduction and External
Rotation of the leg applies pressure on the SI joint of the affected side.
Compression on the pelvis with the patient lying lateral position with the affected
side away from examiner hand. The joint commonly affected with degenerative
scoliosis and rheumatological disorders.
N.B. FABER or Patrick’s test is used to identify the presence of hip pathology by
attempting to reproduce pain in the hip, lumbar spine or sacroiliac region.